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Event Notification Report for September 09, 2010

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
09/08/2010 - 09/09/2010

EVENT NUMBERS
462494624646241462424624346296462384623946240

General Information or Other
Event Number: 46249
Rep Org: WISCONSIN RADIATION PROTECTION
Licensee: MARSHFIELD CLINIC
Region: 3
City: WESTON   State: WI
County:
License #: 141-1162-01
Agreement: Y
Docket:
NRC Notified By: CHRIS TIMMERMAN
HQ OPS Officer: VINCE KLCO
Notification Date: 09/14/2010
Notification Time: 12:57 [ET]
Event Date: 09/09/2010
Event Time: 00:00 [CDT]
Last Update Date: 09/14/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
Person (Organization):
DAVID HILLS (R3DO)
MICHELE BURGESS (FSME)
Event Text
AGREEMENT STATE REPORT - DELIVERED DOSE IS DIFFERENT FROM THE PRESCRIBED DOSE

The following information was received by facsimile:

"On September 14, 2010, the Department [Wisconsin Department of Health Services] received a facsimile from the licensee's Radiation Safety Officer (RSO) that a medical event occurred on September 9, 2010, involving a permanent implant of I-125 seeds for a prostate manual brachytherapy procedure where the total dose delivered differs from the prescribed dose by 20% or more. This is a medical event as described in DHS 157.72(1)(a)1. The prescribed dose was 145 Gy; the dose delivered was 80 Gy. The licensee uses D80 < 80% as their dose based criteria for determining medical events. Using the licensee's dose based criteria of D80 < 80% the dose received by the prostate was 55% of the intended dose. The underdose was identified during the post-implant planning for the procedure. The RSO indicated that the possible cause was the maximum insertion depth was 0.6 cm below the base of the prostate gland and all needles were implanted distal to the base resulting in the area being 'cold'. Possible corrective actions are under review by the licensee's staff and a one month post-implant CT is planned to determine the impact to the patient.

"[Department] inspectors will investigate this medical event on September 16, 2010."

Wisconsin Event Report: WI100015

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.


Power Reactor
Event Number: 46246
Facility: TURKEY POINT
Region: 2     State: FL
Unit: [] [4] []
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: MIKE COEN
HQ OPS Officer: VINCE KLCO
Notification Date: 09/10/2010
Notification Time: 19:46 [ET]
Event Date: 09/09/2010
Event Time: 15:34 [EDT]
Last Update Date: 09/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ROBERT HAAG (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
4 M/R N 0 Hot Standby 0 Hot Standby
Event Text
MANUAL REACTOR TRIP DURING STARTUP DUE TO A CONTROL BANK STEP COUNTER FAILURE

"During a Unit 4 reactor startup on 9/9/2010 while the reactor was subcritical in Mode 3, the Control Bank C Group 1 Step Counter failed [due to a battery failure]. The reactor trip breakers were opened in accordance with procedures as required by the Action of Technical Specification 3.1.3.3. All rods fully inserted. The unit remained in Mode 3. This was a manual actuation of the reactor protection system.

"This report is made in accordance with 10 CFR 50.72(b)(3)(iv)(A) - Valid actuation of the Reactor Protection System. This is a late report. Reportability was not recognized at the time of the event as a result of misleading guidance in 0-ADM-115 'Notification of Plant Events' [site specific] procedure. A condition report is being initiated [by the licensee] to evaluate procedure changes to avoid further occurrences."

The licensee notified the NRC Resident Inspector.


Power Reactor
Event Number: 46241
Facility: INDIAN POINT
Region: 1     State: NY
Unit: [] [3] []
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: DON DEWEY
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/10/2010
Notification Time: 00:29 [ET]
Event Date: 09/09/2010
Event Time: 21:29 [EDT]
Last Update Date: 09/10/2010
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):
WILLIAM COOK (R1DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
3 M/R Y 100 Power Operation 0 Hot Standby
Event Text
MANUAL REACTOR TRIP DUE TO SERVICE WATER LEAK IN THE MAIN GENERATOR EXCITER HOUSING

"On September 9, 2010, at approximately 2129 hours [EDT], Indian Point 3 manually tripped the reactor from the control room following indications of a service water leak in the Main Generator Exciter housing. Unit 3 is currently stable in mode 3. All automatic actions occurred as required. All control rods fully inserted. No primary or steam generator safety relief valves lifted. The motor driven auxiliary feedwater pumps automatically started on low steam generator level as designed. Decay heat removal is via the steam generators to the main condenser. Offsite power is available and supplying all safeguards busses.

"Unit 2 is unaffected and remains in Mode 5 in a forced outage for 21 RCP [Reactor Coolant Pump] repair.

"During the Fast Bus Transfer [the] 34 Reactor Coolant Pump tripped. The cause is being investigated.

"There was an inadvertent release of CO2 to 31 Main Boiler Feed Pump. The cause was due to the suction relief valve lifting which has subsequently reseated.

"The NRC Sr. Resident Inspector and New York State Public Service Commission have been notified."

The reactor is currently being maintained at normal operating temperature and pressure.


Power Reactor
Event Number: 46242
Facility: KEWAUNEE
Region: 3     State: WI
Unit: [1] [] []
RX Type: [1] W-2-LP
NRC Notified By: BRAD GAUGER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/10/2010
Notification Time: 13:47 [ET]
Event Date: 09/09/2010
Event Time: 15:20 [CDT]
Last Update Date: 09/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHRISTINE LIPA (R3DO)
Power Reactor Unit Info
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
EMERGENCY SIRENS INADVERTENTLY ACTUATE

"Spurious siren activation at Point Beach affects associated sirens (P001 - P010) at Kewaunee Power station. A separate 50.72 notification is to be made for Kewaunee per procedure GWP-11.08.04.

"At 1216 CDT, 09/10/10 station EP personnel notified the control room staff that an inadvertent activation of EP sirens occurred for the Point Beach Station at 1520, 09/09/10. This information was relayed to the EP personnel via Manitowoc County EP personnel, who had received the information from Point Beach personnel previously. Below is the information from the Point Beach notification:

"At 1520 CDT, Point Beach was notified by Manitowoc County Sherriff's Department (MCSD) and citizens of audible EP siren actuation in the city of Two Rivers and the town of Two Creeks, WI. System troubleshooting was in progress at the time of actuation.

"Alert and Notification System siren configuration was restored to normal at approximately 1630 CST, 09/09/10. All required ANS sirens were 'poll tested' and are fully functional.

"Further reviews indicated that sirens P-001 through P-013 (13 sirens) had each simultaneously received a 180 second activation. At this time the cause of the activation signal is unknown. All troubleshooting and testing are currently suspended; event investigation has commenced."

The licensee notified the NRC Resident Inspector.


Fuel Cycle Facility
Event Number: 46243
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
Region: 2     State: NC
Unit: [] [] []
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
LEU FABRICATION
LWR COMMERICAL FUEL
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: VINCE KLCO
Notification Date: 09/10/2010
Notification Time: 14:00 [ET]
Event Date: 09/09/2010
Event Time: 14:30 [EDT]
Last Update Date: 09/10/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
PART 70 APP A (b)(1) - UNANALYZED CONDITION
Person (Organization):
ROBERT HAAG (R2DO)
SHEENA WHALEY (NMSS)
Event Text
ACCIDENT EVALUATION IMPROPERLY ANALYZED IN THE INTEGRATED SAFETY ANALYSIS

"During a GNF-A [Global Nuclear Fuel-Americas] review of the Fuel Manufacturing Operation (FMO) Integrated Safety Analysis (ISA), it was determined at [1430 EDT] on September 9, 2010 that the accident evaluation associated with hydrogen containment in the Dry Conversion Process was improperly analyzed in the ISA. A loss of hydrogen containment was analyzed in the ISA, however appropriate Items Relied on for Safety (IROFS) to prevent or mitigate a hydrogen explosion, resulting in a loss of UF6 or HF containment, were not identified in the ISA.

"The affected equipment was promptly shut down on September 9, 2010. Existing hydrogen detection systems were augmented to assure controls are available and reliable to perform their intended safety functions as interim compensatory measures. These controls were functionally verified prior to restart of the affected operations at 2230 [EDT] on September 9, 2010. The interim controls will be designated as IROFS upon completion of the ISA documentation update currently underway.

"This event is being reported pursuant to the reporting requirements of 10CFR70 Appendix A(b)(1) within 24 hours of discovery."

The licensee considers this discovery to be of low safety significance because the discovery did not result in an unsafe condition. The required IROFS have been identified and are in place.

The licensee notified the NRC Region 2 Office, the North Carolina Radiation Protection Section and the New Hanover County Emergency Preparedness Organization.


General Information or Other
Event Number: 46296
Rep Org: ABB, INC.
Licensee: ABB, INC.
Region: 1
City: CORAL SPRINGS   State: FL
County:
License #:
Agreement: Y
Docket:
NRC Notified By: CHAD BUCKWALTER
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/30/2010
Notification Time: 17:35 [ET]
Event Date: 09/09/2010
Event Time: 00:00 [EDT]
Last Update Date: 09/30/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21 - UNSPECIFIED PARAGRAPH
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
MARK LESSER (R2DO)
PART 21 GROUP
Event Text
PART 21 REPORT ON SOLID STATE RELAYS

ABB, Inc. notified the NRC of solid state relays that failed to comply with ABB manufacturing specifications. Subject relays are 27H catalog numbers 411R0175-DP-1E and 411R0175-1E. The failure to comply is in regard to improper installation of a jumper on the main printed circuit board (PCB) of the relay. Manufacturing specifications require the jumper leads to extend far enough beyond the surface plane of the PCB to ensure proper connection. The jumper enables the relay to provide high-speed, instantaneous trip capability. If the jumper were not installed properly, the trip function may be erratic. The subject relays were manufactured between October 1, 2009 and September 9, 2010.

Two safety-related versions of this relay have been purchased by South Texas Project. ABB, Inc. is investigating whether any nuclear plants have purchased the affected relays for use in non safety-related applications.

ABB will be notifying South Texas Project of this defect.


Power Reactor
Event Number: 46238
Facility: ROBINSON
Region: 2     State: SC
Unit: [2] [] []
RX Type: [2] W-3-LP
NRC Notified By: GARRETT SANDERS
HQ OPS Officer: DONALD NORWOOD
Notification Date: 09/09/2010
Notification Time: 18:04 [ET]
Event Date: 09/09/2010
Event Time: 14:37 [EDT]
Last Update Date: 09/09/2010
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):
ROBERT HAAG (R2DO)
Power Reactor Unit Info
Unit SCRAM Code RX Crit Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 100 Power Operation 0 Hot Standby
Event Text
REACTOR TRIP DUE TO OVERTEMPERATURE DELTA-T SIGNAL

"At 1437 hours EDT on September 9, 2010, with the unit in Mode 1 at 100% power, an automatic reactor trip occurred. The reactor trip signal was based on the Overtemperature Delta-T reactor protection function.

"During the event, the steam generator power operated relief valves (PORVs) and one pressurizer PORV briefly opened and re-closed, in response to pressure changes in the steam generators and pressurizer due to the plant transient condition. The Auxiliary Feedwater System automatically actuated, as expected, and provided feedwater to the steam generators. The main steam safety valves did not open during the event. All control rods indicated fully inserted following the reactor trip.

"The normal post-trip electrical lineup is providing power to the plant and the electrical system is stable. Decay heat is being removed via the condenser. The reactor is currently stable in Mode 3.

"There was an indication of an approximate 0.65 gpm leak to the pressurizer relief tank following the reactor trip. The isolation valve to the pressurizer PORV that opened during the reactor trip was closed and the leak indication stopped. The indicated leakage was within Technical Specification leakage rate limits.

"The cause of the reactor trip and indication of pressurizer PORV leakage is under investigation."

The licensee notified the NRC Resident Inspector.


General Information or Other
Event Number: 46239
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: TTM TECHNOLOGIES
Region: 4
City: SAN DIEGO   State: CA
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: RON YONEMITSU
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2010
Notification Time: 18:45 [ET]
Event Date: 09/09/2010
Event Time: 14:50 [PDT]
Last Update Date: 09/09/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
Person (Organization):
BLAIR SPITZBERG (R4DO)
JACK FOSTER (FSME)
Event Text
MISSING TRITIUM EXIT SIGN

The following information was received by e-mail:

"[The licensee] reported that during demolition work by their Maintenance Staff a wall with a tritium exit sign was demolished and the debris was removed from the facility.

The manufacturer of the sign is Safety Light. [The licensee] will investigate the model of the sign that was installed.

[The licensee] confirmed that the debris has left their facility as waste.

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


Power Reactor
Event Number: 46240
Facility: POINT BEACH
Region: 3     State: WI
Unit: [1] [2] []
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JAMIE WEIGANDT
HQ OPS Officer: VINCE KLCO
Notification Date: 09/09/2010
Notification Time: 20:25 [ET]
Event Date: 09/09/2010
Event Time: 15:20 [CDT]
Last Update Date: 09/12/2010
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
CHRISTINE LIPA (R3DO)
Power Reactor Unit Info
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
EMERGENCY SIRENS INADVERTENTLY ACTUATE

"At 1520 [CDT], Point Beach was notified by Manitowoc County Sheriff's Department (MCSD) and citizens of audible EP Siren actuation in the City of Two Rivers and the Town of Two Creeks, WI. System troubleshooting was in progress at the time of actuation.

"Alert and Notification System Siren configuration was restored to normal at approximately 1630 [CDT]. All required ANS sirens were 'Poll tested' and are fully functional.

"Further reviews indicated that Sirens P-001 through P-013 (13 sirens) had each simultaneously received a 180 second activation. At this time the cause of the activation signal is unknown. All troubleshooting and testing are currently suspended; event investigation has commenced."

The licensee notified the NRC Resident Inspector.

* * * UPDATE FROM RIVAS TO KLCO ON 9/12/10 AT 1156 * * *

"This notification is an update to ENS notification #46240 made by Point Beach.

"Notification #46240 was submitted September 9 at 2025 EDT regarding Point Beach notification by Manitowoc County Sheriff's Department (MCSD) and citizens of audible EP Siren actuation in the City of Two Rivers and the town of Two Creeks, WI. System troubleshooting was in progress at the time of actuation.

"This notification is to inform [the NRC] of the planned press release to inform the citizens of the affected communities of the event.

"At 0834 CDT 9/12/2010 Point Beach issued a letter to the Editor of Manitowoc Times Herald Times Reporter Newspaper regarding inadvertent Siren Activation.

"Corrective actions have been taken in the [Point Beach] EP siren maintenance program to avoid a recurrence and the Site Resident NRC Inspector has been notified."

Notified the R3DO (Lipa).