|Entered date||Event description|
|ENS 45371||21 September 2009 10:45:00|
Planned preventive maintenance and testing activities are being performed on the Hatch Nuclear Plant's Technical Support Center (TSC) HVAC system on September 21, 2009. These maintenance activities include the performance of preventive maintenance on the TSC air handling unit, condensing unit and fan and testing of the filter train. These work activities are planned to be completed within the (12) hour day shift on 9/21/2009. During the time these activities are being performed, the TSC air handling unit, TSC condensing unit, TSC filter train and the fan unit for the TSC filter train will not be available for operation. As such, the TSC HVAC will be rendered non-functional during the performance of this work activity. If an emergency condition occurs during the time these work activities are being performed which requires activation of the TSC, the contingency plan calls for utilization of the TSC, as long as radiological conditions allow for habitability of the facility. Procedure 73EP-EIP-063-0, Technical Support Center Activation, provides instructions to direct TSC management to the Control Room and TSC support personnel to the Simulator Building to continue TSC activities if it is necessary to relocate from the primary TSC so that TSC functions can be continued. This event is reportable per 10CFR50.72 (b)(3)(xiii) as described in NUREG-1022, Rev. 1 since this work activity affects an emergency response facility for the duration of the evolution. The licensee notified the NRC Resident Inspector.
Maintenance to the TSC has been completed and the TSC is fully functional. The licensee notified the NRC Resident Inspector. R2DO (Bonser) notified.
|ENS 45370||21 September 2009 01:44:00||At 1826 on Sept 20, 2009, a lightning strike caused a disruption of power to offsite communications. At 1853, ENS communications from Sequoyah Nuclear Plant to the NRC were verified. At 2129, Sequoyah Nuclear Plant was notified the ERDS was not linked to the CECC (Offsite Emergency Operating Facility) or the NRC. At 2218, it was discovered the NRC could not contact Sequoyah Nuclear Plant by the ENS, but Sequoyah Nuclear Plant could still contact the NRC using ENS. At 2240, backup phone communications with satellite phone and cell phones were established between Sequoyah Nuclear Plant and the NRC. Efforts are in progress to restore power to the communications NODE building to restore normal communications. At 0155 the NRC verified 2 way communications via ENS with the licensee. The licensee will notify the NRC Resident Inspector.|
|ENS 45351||15 September 2009 10:14:00||The following was provided by the State via e-mail: A radiographer assistant employed by the company for about ten months may have been overexposed. The licensee processes dosimetry every two weeks. The employee's badge for 8-1 to 8-15 returned a reading of 3.077 rem deep dose for the two week period. This placed the employee's total exposure for the calendar year at 3.93 rem. The licensee removed the worker from being involved with licensed materials and initiated an investigation. The worker's badge for 8-16 to 8-31 had already been submitted for processing. On 9/3/09, the licensee was contacted by the dosimetry provider and informed that the worker's deep dose for 8-16 to 8-31 was 12.542 rem. This placed his total annual dose at 16 rem. No unusual exposures on the worker's pocket dosimeter had been recorded at any time. The dosimetry provider indicates the badge exposures are 'irregular'. The licensee contacted Oklahoma DEQ and initiated a thorough investigation. During the period in question, the radiographer assistant had worked with only one radiographer. All work was done at temporary job sites at industrial facilities. The radiographer and assistant insisted that there had been no unusual events or possibility of exposure, that the worker's alarming rate meter had not alarmed, and that pocket dosimeter readings for the period had been normal. The worker insisted he had not been exposed, and he believed someone else had exposed his dosimetry. The company does not allow assistant radiographers to have keys to cameras, and the worker is not approved for unescorted access to IC quantities of radioactive material. Both workers agreed that the assistant radiographer had never had a key to a camera, but investigation revealed that the assistant radiographer had left the worker alone with the unlocked camera while he went to the restroom. The licensee has counseled the radiographer not to do this, and has informed all radiography staff that assistant radiographers must not be left alone with unlocked radiography cameras. The licensee has contacted local medical assistance, and is told that because of the (relatively) low level of the exposure, and it being spread into at least two components, locally-available blood testing will not reliably detect the exposure. Since receipt of the dosimetry report, the licensee is not allowing the worker to work near radioactive materials or x-ray. The licensee does not believe the worker was actually exposed to radioactive material, and wants to use chromosome analysis to test this theory. The State has encouraged the licensee to take steps to investigate whether the exposure was to the badge only, or to the worker.|
|ENS 45330||6 September 2009 20:17:00||Xcel environmental notified the State of Minnesota duty officer of the loss of approximately 1200 Amertap balls from the Unit 1 circulating water system. The Amertap balls are made of foam and are used for condenser tube cleaning. No further actions or notifications are required. The licensee notified the NRC Resident Inspector.|
|ENS 45309||28 August 2009 18:22:00|
On August 28, 2009, the (State) Agency was notified by the licensee that while performing radiological surveys in response to a shipping event, access to an area of their facility not normally controlled for radiological reasons was isolated due to the presence of radioactive contamination. The licensee believes that the radionuclide involved is Curium (Cm) - 244. The licensee is continuing their investigation and cleanup activities. The (State) Agency will provide updates when available. Texas report # I-8661
NSSI became aware of our contamination problem as a result of the shipment of an empty transport container in support of the DOE Offsite Source Recovery Program (OSRP) which operates from Los Alamos. The NSSI facility is used by OSRP as the primary consolidation facility for the Program.
NSSI shipped an empty 30 gallon 6M transport container to Penn State University at University Park, PA on August 20, 2009 by (a delivery company). An attempt was made by the (delivery company) to deliver the package on August 24, but it was refused. The drum was accepted the morning of August 25, 2009.
On receipt, contamination was noted on the lid with another spot on the pallet and on the banding holding the drum to the pallet. OSRP personnel were at the site and confirmed the contamination. (The delivery company) was also notified and arrangements were made to survey the delivering vehicle. No contamination was found on the truck.
NSSI was notified midday and began to make measurements to determine if the contamination could be from the NSSI facility or whether it occurred during transit. NSSI tracked the drum back to its origination point in the NSSI facility and was able to confirm that the area immediately surrounding where the drum had been stored was contaminated. Further surveys and wipes showed activity across the storage area floor. Trace contamination was also found on the pallet banding equipment and on the OSRP source inspection and documentation table. Other spots of low contamination were found on a fork lift and a drum cart that was used to move the transport container that went to Pennsylvania. These areas were decontaminated so the equipment could be utilized.
As the radionuclide has not yet been identified, decontamination is being limited to small spots on the concrete outside the Longhorn building and on equipment or shields that may have been removed from the contaminated area.
NSSI has decided to delay any decontamination activities pending identification of the nuclide. Time will be required to get air sampling set up and operating and to coordinate with the decontamination personnel.
At the moment, the radionuclide, quantity, and physical/chemical form involved has not been specifically identified. Surveys tell us the radioactive material is an alpha emitter. Gamma spectrum tells us that the nuclide is not Am-241. Long term gamma spectrum counts of wipes collected also tend to indicate the absence of Pu-238 and Pu-239 as there is always some Am-241 present with these nuclides. Liquid scintillation identifies the alpha energy as being higher than the 5.4-5.5 MeV from Am-241, the 5.4-5.5 MeV for Pu-238 and the 5.1-5.2 for Pu-239. Polonium 210 would also appear to be excluded as it's alpha energy is only 5.3 MeV. In addition, NSSI handles almost no Po-210. At this time, the primary suspect at this time is Curium-244 which has an alpha energy of 5.7-5.8 MeV. We do expect to have nuclide confirmation within a few days as the State of PA and Los Alamos both have samples for evaluation.
At this point, we do not have any indication of personnel radiation exposure. We will be talking with Los Alamos internal dose assessment people early next week.
Until we have nuclide information and further evaluate the contamination present in the restricted area, the involved area will remain closed to all NSSI personnel. NSSI is currently in the process of contacting the decontamination experts that assisted NSSI several years ago with an Am-241 contamination incident. We expect to be ready to start the decontamination process within the next 2-3 weeks. See also EN #45321 for the Pennsylvania report on the same event. Notified R4DO (Farnholtz) and FSME (McIntosh).
|ENS 45306||27 August 2009 21:40:00||At 1945 on 8/27/09 Indian Point Unit #3 automatically tripped due to a turbine trip signal. The cause for this automatic trip is under investigation. All auxiliary feedwater pumps started as expected. All control rods inserted as expected. Currently, Indian Point #3 is in Mode 3. The reactor coolant system is at Normal Operating Temperature, Pressure and Level. Offsite power is available and supplying all safeguards busses. Heat removal is to the main condenser via the steam dumps. Indian Point Unit 2 is unaffected and remains in Mode 1 at 100% power. The (NRC) Resident Inspector has been notified.|
|ENS 45304||27 August 2009 12:51:00||The licensee facility experienced a large fire on 08/27/09 starting at approximately 0500. The facility involved houses 4 devices containing radioactive materials. These devices are used for process control. Three (3) of the devices contain 200 milliCuries of Cs-137 (Texas Nuclear Model #5202) and one device contains 100 milliCuries of Cs-137 (Texas Nuclear Model #7062BP). Currently the floors that contain the devices are believed to be intact. This however may change as the condition of the building degrades. The Mine Safety and Health Administration (MSHA) is currently not allowing anyone into the facility due to the treacherous conditions. It is not known when the licensee will be able to determine the integrity of the sources. The Logan County, West Virginia Fire Department is responding to the fire, are aware of the sources, and are wearing appropriate personnel protective equipment. The firefighters have been using a Geiger counter to ensure radiological safety. Initial surveys of firefighters that entered the building were negative. The source of the fire is still under investigation, but the licensee does not believe the fire to be suspicious in nature.|
|ENS 45259||12 August 2009 18:01:00||The following was provided by the State via e-mail: (An) 8 mCi Cs-137 source (was) stolen from PaveTex at 16:30 CST 8/11/2009 at the O'Reilly Auto Parts on US 87 in Big Spring, TX. (The) Source was in a Troxler model 4640 thin layer density gauge, serial no. 1280. (The State was) notified (at) 15:30 CST on 8/12 that the source was located by a member of the public at the TA Truck stop on I-20 at US-87 north of town and that (the) site RSO had sent someone to pick up (the) gauge. Texas Incident # - I-8654 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.|
|ENS 45257||11 August 2009 14:50:00|
The State of North Carolina discovered 2 missing static eliminators containing 500 microCi of Po-210 and 80 microCi of Am-241. The licensee was billed for the annual fees related to these gages and notified the State that they no longer had the gages in their possession. The State sent an inspector to investigate the situation. The inspector discovered that the manufacturing facility had been relocated to Vietnam 3 years ago. When this occurred the licensee believes it is possible that the sources were relocated with the majority of the manufacturing facility assets to the Vietnam location at that time. The State is continuing to follow-up with the licensee to determine disposition of these sources.
* * * UPDATE ON 8/13/09 AT 1022 EDT FROM BARNES TO HUFFMAN * * *
A representative of the State of North Carolina provided the following additional information about the lost sources: The Am-241 source was manufactured by Pyrotronics. Model number F315A. Serial Number 1000635. Date received - 1971 The Po-210 source was manufactured by Nuclear Products. Model number 2U500. Serial Number Unknown. Date received - 1989 R1DO (Cook) and FSME (McIntosh) have been notified of this update. 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.
|ENS 45363||19 September 2009 09:49:00||A licensee radio-pharmacist was preparing Flourine-18 (F-18) doses for use, when a manipulator malfunction occurred. The radio-pharmacist continued to prepare the F-18 manually instead of securing the process. This led to a potential dose to the radio-pharmacist's right hand of greater than 50 rem. This dose is a rough estimate from whole body dose values and reconstruction of the event due to the fact the radio-pharmacist was not wearing any dosimetry on the extremity. The State will continue to investigate this event and provide additional information as it become available.|
|ENS 45047||8 May 2009 08:02:00|
On May 8, 2009, the Safety Parameter Display System (SPDS) will be removed from service at approximately 1000 hours for Salem Unit 1 to perform planned maintenance to the system. The maintenance consists of the replacement of the uninterruptable power source (UPS) to improve the reliability of the SPDS. The removal of SPDS will also affect the transmission of Salem Unit 1 data from the emergency response data system (ERDS). Appropriate compensatory measures will be in place while SPDS is out of service. SPDS capability is scheduled to be restored using a temporary power feed later today. The licensee notified the NRC Resident Inspector.
The Salem Unit 1 Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) were returned to service at 1530 hours. The licensee will notify the NRC Resident Inspector. Notified the R1DO (Caruso).
|ENS 45031||30 April 2009 00:48:00||At 2230 on April 29, 2009, with Nine Mile Point Unit 1 and Unit 2 operating at 100% reactor power, Oswego County Emergency Management notified the Unit 1 and Unit 2 Control Rooms that the National Weather Service had notified them that the Tone Alert Radios had been out of service since 1938 (on 4/29/09). At 0015 on April 30, Oswego County Emergency Management notified the Control Rooms that the Tone Alert Radios had been restored to service as of 0012, April 30, 2009. This impacted the ability to readily notify a portion of the Emergency Planning Zone (EPZ) Population for the Nine Mile Point and JAF (James A. FitzPatrick see EN# 45030) Nuclear Power Plants. This failure meets NRC 8 hour reporting criterion 10 CFR 50.72(b)(3)(xiii). The County Alert Sirens which also function as part of the Public Prompt Notification System remained operable. The loss of the Tone Alert Radios constitutes a significant loss of emergency offsite communications capability. Compensatory measures were verified to be available should the Prompt Notification System be needed. This consists of utilizing the hyper reach system which is a reverse 911 feature available from the county 911 center. Local Law Enforcement Personnel are also available for 'Route Alerting' of the affected areas of the EPZ. The event has been entered into the corrective action program, and the (NRC) Resident Inspector has been briefed, and the state PSC will also be notified.|
|ENS 44985||12 April 2009 13:47:00||On Sunday, April 12, 2009 at about 0430 PDT, Southern California Edison (SCE) discovered that approximately 300 gallons of sulfuric acid had overflowed from the Unit 3 Sulfuric Acid Day Tank. The acid was contained within a berm around the tank, and there was no release to the environment. SONGS (San Onofre Nuclear Generating Station) Hazardous Materials personnel are in the process of responding to this event. Once onsite they will remove the acid from the berm for disposal at a hazardous waste facility. The overflow was caused by leakage from the Bulk Acid Tank to the Acid Day Tank. At about 1004 PDT, SCE notified the San Diego County Department of Environmental Health, and at about 0940 PDT, SCE notified the California Office of Emergency Services. SCE is making this notification in accordance with 10CFR50.72(b)(2)(xi). At the time of the report, SONGS Unit 2 is in Mode 1 at approximately 99% power and Unit 3 is in Mode 1 at approximately 100% power. The NRC Senior Resident Inspector has been notified of this occurrence and will be provided with a copy of this report.|
|ENS 44983||10 April 2009 18:21:00||On Friday April 10, 2009, at about 0900 PDT, Southern California Edison (SCE) discovered that approximately 1,000 gallons of sulfuric acid had overflowed from the Unit 3 Sulfuric Acid Day Tank. The acid was contained within a berm around the tank, and there was no release to the environment. SONGS (San Onofre Nuclear Generating Station) Hazardous Materials personnel responded to the event, and are in the process of removing the acid from the berm for disposal at a hazardous waste facility. The overflow was caused by leakage from the Bulk Acid Tank to the Acid Day Tank. At about 1340 PDT, SCE notified the San Diego County Department of Environmental Health, and at about 1353 PDT, SCE notified the California Office of Emergency Services. SCE is making this notification in accordance with 10CFR50.72(b)(2)(xi). At the time of this report, SONGS Unit 2 is in Mode 1 at approximately 99% power and Unit 3 is in Mode 1 at approximately 100% power. The NRC Senior Resident Inspector has been notified of this occurrence and will be provided with a copy of this report.|
|ENS 44982||10 April 2009 12:43:00||At 0538 on Friday, April 10, 2009, Nine Mile Point Unit One manually tripped the turbine at approximately 28% rated power in response to rising turbine bearing vibrations. Following the manual turbine trip, the High Pressure Coolant Injection (HPCI) system automatically initiated on the turbine trip signal. The HPCI system initiation signal was reset immediately following the turbine trip. Reactor water level was maintained in the normal operating range throughout the transient. At Nine Mile Point Unit One the HPCI system is a mode of operation of the feedwater and condensate system. It is not an Emergency Core Cooling System (ECCS). A HPCI system actuation signal on a turbine trip is an expected response of the HPCI system. Nine Mile Point Unit 1 remains at power since the turbine was tripped at a power level that is within the capacity of the turbine bypass valves. 10 CFR 50.72(b)(3)(iv)(A) requires reporting within 8 hours when a valid actuation of the feedwaler coolant injection system occurs. The event has been entered into the corrective action program. There are no other adverse impacts to the station based on this event. The NRC Resident Inspector was notified.|
|ENS 44978||8 April 2009 17:22:00||The purpose of this report is to notify the NRC of an untimely death involving a Dominion worker at the Millstone station. Specifically, at 1406 EDT the Unit 3 Control Room was notified that an individual located outside the Protected Area had lost consciousness. The site emergency medical team responded and an ambulance was requested at 1410. At 1455 the Unit 3 Control Room was notified via Lawrence Memorial Hospital that the individual passed away. The untimely death was not occupationally related. State and local offsite notifications were made. The licensee notified the NRC Resident Inspector.|
|ENS 44934||26 March 2009 08:29:00||At approximately 0452 on 03/26/09, Sequoyah Unit 1 received an Automatic Reactor trip on Reactor Coolant Pump Busses Undervoltage. A loss of Common Service Station Transformer C caused a loss of power to the 1B and 1D Unit Boards. The 1B and 1D unit boards are the 6.9Kv electrical feeds to the 1-2 and 1-4 RCPs, respectively. RCPs 1-1 and 1-3 are running. ESF functions initiated as designed including Aux Feed Water auto-start, automatic Feedwater isolation, and auto-start of all four EDGs. The 1A Shutdown Board is being powered from the 1A EDG. The plant is currently being maintained in Mode 3 at approximately 547 degrees F /2235 PSIG. Decay heat is being removed by the auxiliary feedwater system and Steam Generator Atmospheric Relief valves. The cause of the loss of Common Service Station Transformer C is not known at this time and investigation is ongoing. All rods inserted as expected. No safety related equipment is out of service. Unit 1 has no known Steam Generator Tube leaks. The licensee notified the NRC Resident Inspector.|
|ENS 44935||26 March 2009 08:29:00||At approximately 0452 on 03/26/09, Sequoyah Unit 2 received an Automatic Reactor trip on Reactor Coolant Pump Busses Undervoltage. A loss of Common Service Station Transformer C caused a loss of power to the 2B and 2D Unit Boards. The 2B and 2D unit boards are the 6.9Kv electrical feeds to the 2-2 and 2-4 RCPs, respectively. RCPs 2-1 and 2-3 are running. ESF functions initiated as designed including Aux Feed Water auto-start, automatic Feedwater isolation, and auto-start of all four EDGs. The 2A Shutdown Board is being powered from the 2A EDG. The plant is currently being maintained in Mode 3 at approximately 547 degrees F /2235 PSIG. Decay heat is being removed by the auxiliary feedwater system and Steam Generator Atmospheric Relief valves. The cause of the loss of Common Service Station Transformer C is not known at this time and investigation is ongoing. All rods inserted as expected. No safety related equipment is out of service. Unit 2 has no known Steam Generator Tube leaks. The licensee notified the NRC Resident Inspector.|
|ENS 44894||6 March 2009 17:06:00||At 1440 a gasoline spill occurred while filling a company vehicle from a mobile gasoline truck. The auto-fill valve failed to shut off immediately when the gas tank was full and sprayed / spilled a small quantity (< 1 gallon) of gasoline on the ground. The spill was immediately terminated. This gasoline travelled to the nearest storm drain via water from melting snow. The Operations department was notified at 1445. Initial investigation revealed that the next storm drain in line to the river from the affected storm drain had significant water flow through it from the melting snow and no sheen was observed. There was also no oil sheen visible in the Delaware River. Based on the available indications, a 15 minute report to the State of New Jersey was completed at 1458 in accordance with the Hope Creek Event Classification Guide. The National Response Center was also notified at 1600. Spill recovery actions are in progress and expected to complete before the end of the day. The NRC Resident Inspector has been informed. Plant operation was unaffected, no safety systems were impacted.|
|ENS 44940||27 March 2009 08:40:00||This 60-day report, as allowed by 10 CFR 50.73(a)(1), is being made under the reporting requirement in 10CFR50.73(a)(2)(iv)(A) to describe an unplanned, invalid actuation of specified systems, specifically the Unit 3 Primary Containment Isolation System (PCIS). On 3/2/09, at approximately 1155 hours, Unit 3 experienced an invalid PCIS partial isolation. Associated with the momentary shorting of a terminal lead during maintenance, a fuse was blown and power was lost to nine Primary Containment Isolation Valves (PCIVs). This resulted in two of the PCIVs re-positioning to the closed position. The re-positioned PCIVs were the AO-3-07B-3509 (Inner Drywell Exhaust Valve) and the AO-3-16-5235 (Instrument Nitrogen System Suction Valve). Closure of these valves affected the Containment Atmospheric Control (CAC), Containment Atmospheric Dilution (CAD) and Containment Instrument Nitrogen systems. Closure of these valves was the expected response for loss of power to this portion of the PCIS control circuitry. The fuse was replaced and the valves were restored to an operable condition by 1235 hours on 3/2/09. The invalid PCIS isolation was a result of the momentary shorting of an energized terminal lead associated with preventive maintenance to replace a pressure switch associated with PCIV AO-3-07B-3519 (Nitrogen Supply Purge Valve). This issue has been entered into the site Corrective Action Program (CR 887441) for evaluation and implementation of further corrective actions. The NRC resident has been informed of this notification.|
|ENS 44885||2 March 2009 12:57:00||A contract employee associated with the Unit 2 refueling outage died this morning from an apparent heart attack. The death was not the result of any industrial safety issue and did not occur in a contaminated area. The individual was treated by the onsite first responders who administered CPR and AED (automatic external defibrillator). He was transported via ambulance to Dosher Memorial hospital where he was pronounced dead at 0915. OSHA is being notified of the event under the requirements of 29 CFR 1904. The licensee notified the NRC Resident Inspector.|
|ENS 44878||25 February 2009 16:51:00|
A licensed employee had a confirmed positive test for alcohol during a for-cause fitness-for-duty test. The employees access to the plant has been suspended. Contact the Headquarters Operations Officer for details. The licensee will inform state/local agencies and has informed the NRC Resident Inspector.
The licensed employee's for-cause fitness-for-duty test also confirmed positive for marijuana. The employee's access to the plant has been revoked. Notified the R2DO (Rich). The licensee will inform state/local agencies and has informed the NRC Resident Inspector.
|ENS 44873||24 February 2009 20:58:00||The following was provided by the state via email: The licensee discovered a damaged Am-241 alpha source during a routine sealed source inventory and leak test on Monday February 23, 2009. A pinhole leak was discovered through the source active area. After further assessment on February 24, 2009, it was determined that more than half of the source activity cannot be located. The Am-241 source was manufactured by North American Scientific (model # CAL2702, source #67250) with an activity of 845.8 nCi (nanocuries) as of October 1, 2005. Currently there is 160 nCi remaining on the Am-241 source and 160 nCi of contamination on the sponge insert in the source container. 521 nCi of the activity cannot be accounted for. The licensee has performed preliminary contamination surveys of the source storage area, source use area, and the common lab area. The survey were performed using GM survey meters with pancake detectors and wipes counted with a liquid scintillation counter. No significant contamination was found. The licensee will perform additional surveys and continue to investigate the cause of this incident. 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.|
|ENS 44856||17 February 2009 11:16:00|
At 04:05 hours EST, on February 17, 2009, the Plant Process Computer System was removed from service to perform a planned maintenance on the inverter power supply. The plant computer provides monitoring capability for the Safety Parameter Display System (SPDS). The expected duration of plant computer inoperability is approximately 16 hours. The loss of the plant computer requires alternate methods, as described in plant procedures, to be used. Therefore, appropriate assessment of plant conditions, notifications and communications can still be made, if required, during the time that the plant computer is inoperable. This report is being made in accordance with 10 CFR 50.72(b)(3)(xiii) which is any event that results in a major loss of emergency assessment capability, offsite response capability or offsite communications capability. As previously stated, alternate means remain available to assess plant conditions, make notifications and accomplish required communications, as necessary. An additional notification will be provided when plant computer operability is restored. The NRC Senior Resident Inspector has been notified.
The SPDS was restored at 1545 EST. The licensee informed the NRC Resident Inspector. Notified R1DO (Jackson).
|ENS 44854||16 February 2009 09:45:00||At 0513 on 2/16/09, the Unit 2 reactor was manually scrammed in accordance with alarm response procedure 2-ARP-9-8A 'TURBINE TRIP TIMER INITIATED'. Other associated alarms and indications both locally and in the Main Control Room indicated a failure of the stator cooling water system. The exact cause of the failure is still being investigated. All systems responded as expected to the insertion of the manual scram. No ECCS injection was initiated or required, and all expected containment isolation and initiation signals were received. This event is reportable within 4 hours per 10CFR 50.72(b)(2)(iv)(B) 'any event or condition that results in actuation of the reactor protection system (RPS) when the reactor is critical except when the actuation results from and is part of a pre-planned sequence during testing or reactor operation'. It is also reportable within 8 hours per 10CFR 50.72(b)(3)(iv)(A) and requires an LER within 60 days per 10CFR 50.73(a)(2)(iv)(A). All rods inserted fully into the reactor. The electrical power system is in a normal shut down configuration. Decay heat removal is through the main condenser via the turbine bypass valves. There is no impact on Units 1 and 3. The NRC resident inspector has been notified.|
|ENS 44812||28 January 2009 13:24:00||At 0834 on 01/28/2009 it was identified that a Steam Exclusion door was held open by a door chock installed on the door for less than 15 minutes. The door was open to ventilate the room during venting of carbon dioxide piping for routine maintenance. A Maintenance Mechanic was stationed at the door as per procedure. This door would have allowed steam into the emergency safeguards bus area from the Carbon Dioxide Tank room. This could have resulted in both Trains of ESF Equipment failing to perform their required functions. Upon discovery the door chock was disengaged to allow the door to self-close if required. The NRC Resident Inspector has been notified.|
|ENS 44811||28 January 2009 12:16:00|
On January 28, 2009 at 0730 the Division 2 Emergency Equipment Cooling Water System (EECW) was declared inoperable due to a blown control power fuse in the bucket for the P4400F604 - Div 2 EECW Supply to Control Rod Drive (CRD) pumps. This is a normally open valve and is required to close upon EECW initiation to remove non-essential loads. The blown control power fuse would have prevented this action from occurring. The ECCW System cools various safety related components including the High Pressure Coolant Injection (HPCI) System Area Cooler. An unplanned HPCI inoperability occurred due to the Division 2 EECW inoperability based on a loss of the HPCI System Area Cooler. A 14 day Limiting Condition for Operation (LCO) was entered for HPCI per LCO 3.5.1. The control power fuse was replaced, EECW and HPCI were declared operable, and LCO 3.5.1 exited on January 28, 2009 at 1025. This report is being made pursuant to 10CFR50.72(b)(3)(v)(D) as a condition that at the time of discovery could have prevented the fulfillment of a safety function needed to mitigate the consequences of an accident, based on loss of a single train safety system. The NRC Resident Inspector has been notified.
The As-Found condition of the Division 2 Emergency Equipment Cooling Water (EECW) Control Rod Drive (CRD) Pump Supply Valve and High Pressure Coolant Injection (HPCI) System Room Cooler were evaluated. The HPCI System Room Cooler was operable with P4400-F604, Division 2 EECW to the CRD supply valve open. Based on an Engineering evaluation of EECW flow during a Loss of Coolant Accident (LOCA) and Non-LOCA conditions with the valve open, there is adequate flow margin in the EECW system. The HPCI Room Cooler had adequate cooling flow to perform its design function. The HPCI room temperature would have been maintained below the HPCI equipment room high temperature isolation setpoint. Additionally, plant procedures provide directions for bypassing the HPCI equipment room high temperature trip. Consequently, there was no loss of HPCI safety function. Declaring HPCI inoperable was conservative and based on initial considerations. Therefore, event notification 44811 is retracted. The Licensee notified the NRC Resident Inspector. Notified R3DO (Lara).
|ENS 44813||28 January 2009 15:48:00||Two medical events were discovered on January 27, 2009, for patients treated during 2005 at VA Greater Los Angeles Healthcare System, Los Angeles, California. These two medical events involved patients who had undergone permanent implant prostate seed brachytherapy using iodine-125 seeds. The resulting seed distributions in the patients were associated with a D90 dose to the treatment site that was less than 80% of the prescribed dose. These patient circumstances are interpreted to meet the definition of a medical event under 10 CFR 35.3045(a)(1)(i). A 15-day written report for the medical events will be submitted to NRC Region III. We have notified our NRC Project Manager (Cassandra Frazier, NRC Region III) of the medical events. A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.|
|ENS 44780||16 January 2009 13:16:00|
The following was provided by the State via e-mail: On 1-15-09, DRH was notified by the Forrest County ERC that JANX Integrity Group had an accident with one of their darkroom trucks off Hwy 59 N., in Hattiesburg, MS. The driver for JANX struck a tree off the side of the interstate causing the vehicle to catch fire. The driver then left the scene of the accident. The radiography camera, SPEC-150, SN 150 (Ir-192, 65 Ci), was not discovered until the fire department saw a 'Caution Radiation Area' sign in the bed of the darkroom truck after extinguishing the fire. Surveys were conducted by firefighter personnel for their safety and to pinpoint the location of the radioactive device in the darkroom truck. The Forrest County ERC contacted an industrial radiography company and MS licensee located in Hattiesburg to take possession of the camera and secure it in their storage vault. The radiography camera was retrieved off the darkroom truck and out of its locked storage box by the MS licensee. The radiography camera was surveyed by the MS licensee before being transported to their storage facility. On 1-15-09, JANX retrieved the radiography camera out of storage for transport back to the manufacturer to assess the damage. DRH took surveys of the darkroom truck and the radiography camera. Radiation measurements were as follows: 24 mR/hr at the surface of the camera; 4 mR/hr at 6 inches from the camera; levels were background at the vehicle. DRH coordinated the receipt of radiography camera between JANX and a MS licensee for delivery back to the manufacturer. MS report number - MS 09001
The following was provided by the State via e-mail: On 1-15-09, swipes were taken on the camera and revealed no removable contamination. Leak test results for the source and DU shielding were received from SPEC on 1-23-09 and also revealed no removable contamination. Notified FSME EO (Chang) and R4DO (Farnholtz).
The following was provided by the State via e-mail: On 1-28-09, DRH received the SPEC - 150, Exposure Device S/N 150 Final Inspection Certificate from SPEC. The camera met the requirements contained in 10 CFR 34.20, ANSI N432 1980, USA/9263/B(U)-96 and SPEC's QA Program approval number 102. Notified FSME EO (White) and R4DO (Cain).
The following information was provided by the state via e-mail: Source was Ir-192, 65 Ci, S/N PJ1606, Source Model G-60. Notified FSME EO (Vontill) and R4DO (Powers).
The following information was provided by the state via e-mail: The State of Mississippi has taken enforcement action and cited their licensee with four violations. Notified R4DO (Gaddy) and FSME EO (Vontill).
The following information was provided by the state via e-mail: On 3/5/09 (the State of Mississippi) received a written report from JANX Integrity Group. This incident has been closed on 3/5/09. Notified R4DO (Proulx), and FSME EO (McIntosh).
|ENS 44774||14 January 2009 16:38:00|
The active source may have movement difficulties and become stuck during source extension or retraction. The problem may occur with the source outside of the HDR unit's tungsten shield. This type of event was first seen in December 2008. This event has occurred three times:
"a) Southwest Regional Cancer Center, Austin TX - December 2, 2008 (see EN #44697) "b) Hershey Medical Center, Hershey PA - December 11, 2008
c) Stanford University Medical Center, Stanford, CA - December 30, 2008 In each case the problem occurred during a routine source exchange and patients were not involved. The emergency retract handle was used in each occurrence to retract the source and park it safely in the HDR unit's tungsten shield. The relationship between the source exchange and the problem is unknown. The affected sites in the United States are as follows: St. Joseph's - Mercy Hospital of Macomb - Clinton Twp., MI Cancer Healthcare Associates Cedars Med Ctr - Miami, FL Providence Hospital - Anchorage, AK Coborn Cancer Center - St. Cloud, MN Stanford University Medical Center - Palo Alto, CA Barnes Jewish #2 - Washington University - St. Louis, MO Mayo Clinic - Rochester, MN DeKalb Medical Center - Decatur, GA Cy-Fair Cancer Center - Houston, TX Billings Clinic - Billings, MT Palm Beach Cancer Institute - West Palm Beach, FL St. Lukes - Bethlehem, PA University of Nebraska Medical Center - Omaha, NE Geisinger Health System - Wilkes-Barre, PA Southwest Regional Cancer Center - Austin, TX Hershey Medical Center - Hershey, PA Carolinas Medical Center - Charlotte, NC Cheyenne Regional Medical Center - Cheyenne, WY Mary Washington Hospital - Fredericksburg, VA Treasure Coast Radiation Oncology - Stuart, FL Mayhill Denton Cancer Center - Denton, TX Hamilton Medical Center - Dalton, GA Providence Hospital - Everett, WA Good Samaritan Hospital - Downers Grove, IL Seattle Cancer Care Alliance - Seattle, WA
After conferring with Region 1 (Gabriel) and NRC HQ (Flannery) the licensee is also reporting this under 10 CFR 30.50(b)(2). Notified R1DO (Burritt) and FSME (Flannery).
|ENS 44777||14 January 2009 23:00:00||Via relay by the N.C. Division of Emergency Management Operations Center, N.C. Radiation Protection Section was notified on 14 Jan 2009 by the Corporate RSO for MISTRAS Holding Group, doing business as Conam Inspection and Engineering Services, Inc/ Quality Services Laboratories, Inc. of a possible extremity over exposure. The possible over exposure occurred during a routine radiography source transfer between a QSA 660 camera containing 22 Curies of Iridium 192 (the old source) and an Ir-50 source exchanger containing 100 Curies of Iridium 192 (the new source). Difficulties in completing the exchange resulted in manual attempts to complete the transfer. The licensee is reporting at the end of the event all radioactive material was confirmed as being appropriately stored and secured. Dosimetry for the licensee staff involved in the event were overnighted to the dosimetry vendor for evaluation, results are pending. Details of the event and status confirmation are to be determined during an onsite investigation by the N.C. Radiation Protection Section on 15 Jan 2009. NC event report #: NC-09-04|
|ENS 44778||15 January 2009 13:59:00||The State of Kansas was notified by a Wal-Mart corporate representative located in Bentonville, AR, indicating that Wal-Mart was unable to account for 126 tritium exit signs (which are general licensed materials) that were used at one time in Wal-Mart stores throughout the state. The Wal-Mart representative informed the state office that Wal-Mart had exhausted searching for the tritium exit signs and considered them to be lost and/or missing. The state was provided a listing from corporate Wal-Mart of the store locations along with information on the tritium exit sign manufacturers, model and serial numbers, and curie content where known. Kansas case number- KS090001 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. 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|
|ENS 44788||20 January 2009 14:11:00||The following was provided by the state via facsimile: Description and Analysis of event: A medical event was discovered at 11:00 AM on January 2, 2009 involving a patient who was undergoing high dose rate brachytherapy (HDR) for papillary serous adenocarcinoma of the uterus. The patient completed 4600cGy of external beam radiation therapy on 9/11/08 and was currently undergoing 3 high dose rate brachytherapy fractions, approximately 3 cm in length, at 500 cGy per fraction. During the patient's second HDR treatment, a review of the first HDR plan showed that the tandem was not fully inserted into the cylinder. The visualization on the CT scan of the placement of the tandem being partially inserted was not recognized by the planner or reviewer of the plan. The dwell positions were therefore placed in the airspace where the tandem should have been inserted versus at the retracted location. The first fraction (12/23/08) was therefore treated approximately 6 cm distal to what was represented by the isodoses on the plan printout. The x-ray (port film) at the time of treatment also showed the tandem not fully inserted into the cylinder. A plan was run with the isodoses placed 6 cm distal to the tip of the tandem channel. The isodoses show that the patient received dose (3 cm of active dwell positions as planned) to the distal vagina versus the proximal vagina as prescribed. The radiation oncologist was immediately notified of the tandem placement after discovery. The prescribing physician (radiation oncologist) notified the patient and the referring physician about the variance that had occurred in the patient's treatment as well as the possible complications. Patient Management: The radiation oncologist explained to the patient that there was no clinically significant increase in possible complications as a result of the HDR treatment to the distal vagina for 1 fraction (12/23/08). After careful review, the radiation oncologist decided he will continue as planned with the third HDR fraction at 500 cGy. He does not expect any increase in bladder or rectal toxicity and expects to see a decrease in normal tissue toxicity. Prevention of Future Occurrence: 1. When the nurse assembles the cylinder applicator, the nurse will measure the tandem length outside the cylinder to ensure the tandem has been inserted to the maximum extent. 2. The dosimetry and physics staff will receive an in-service on the difference in CT image based plans with an emphasis on how the tandem channel looks in the cylinder with the tandem fully inserted versus a partial insertion. 3. The physicists will begin looking at the pre-treatment port film along with the radiation oncologist prior to initiating treatment. Louisiana event number - LA090007 A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.|
|ENS 44725||17 December 2008 10:51:00||On Wednesday, December 17, 2008 a Troxler moisture density gauge, Model 3430 (S/N 37875 with 8mCi of Cs-137 S/N 77-5152; and 40mCi of AmBe-241 S/N 78-2656) was stolen from the bed of a company pick-up truck along with some other field equipment. The transport case was chained as required by company procedures, but the entire case with gauge was noted missing when the technician briefly left the truck unattended. The chain had been cut and the theft was immediately reported to the Dallas Police Department. The area will be canvassed and dumpsters checked to see if the device had been inadvertently discarded. A reward will be posted through a notice that will be distributed to local authorities. TX Case Number I-8591. 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.|
|ENS 44727||17 December 2008 16:07:00||A patient was prescribed a gammaknife procedure to treat trigeminal neuralgia on the right side of the face and the left was treated in error. The prescribed dose was 40 Gray (Gy) to 50% isodose. The patient was notified of the misadministration. There are no expected adverse effects to the patient. The licensee is continuing to investigate this incident to determine the cause of the misadministration and the total dose to the patient. A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.|
|ENS 44723||15 December 2008 22:47:00|
At 1616 on 12/15/08, a plant heating boiler trip resulted in a loss of a reactor building ventilation. The loss of reactor building ventilation resulted in maximum average main steam chase temperatures greater than or equal to 165F. High energy line break (HELB) analysis of piping in the steam chase assumes an initial average temperature prior to the break of 165F. Temperature greater than or equal to 165F in the steam chase challenges EQ qualification of the piping analysis. Abnormal procedures for loss heating boiler and ventilation system failure were entered. C.3 (Shutdown) and C.5-1300 (secondary containment control) were also entered. The plant heating boiler was restarted and ventilation restored prior to power reduction. All systems have been returned to normal. The licensee notified the NRC Resident Inspector.
The licensee is retracting this report based on the following: Monticello is retracting the event reported based on further evaluation, which found that the issue was not an unanalyzed condition that seriously degraded plant safety. The investigation of the event found the peak temperature achieved was 167.2 degrees F and the condition lasted for approximately 11 minutes. Engineering review of Safety System Components found no impact on the equipment for the temperature reached, Additionally, revised High Energy Line Break (HELB) calculations performed with an initial average Steam Chase Room temperature of 180 degrees F before a HELB determined that Safety System components could perform their safety functions. The station has identified the cause for the event and corrective actions will be tracked in the station's corrective action program. Since there was no impact on the equipment in either Environmental Qualification (EQ) or safety function, the temperature of the event was less than the revised calculation temperature, and the unanalyzed condition that existed in the initial event notification report no longer exists and did not result in a condition that seriously degraded plant safety, this event can be retracted. The licensee informed the NRC Resident Inspector. Notified R3DO (Ring).
|ENS 44701||6 December 2008 13:22:00||This 4-hour Non-Emergency notification to the NRC is being made based on a notification to another government agency per 10 CFR 50.72(h)(2)(xi). On December 6, 2008 at 1253 the Control Room was informed by Turkey Point Fossil Environmental personnel that they contacted the Florida Department of Environmental Management and Florida State Warning Point due to overflowing an ash pit for the Turkey Point Fossil Units 1 and 2. The overflow was of industrial waste water with a volume of approximately 2250 gallons and allowed directly into the cooling canal system. The state agency notifications were completed at 1128 on December 6, 2008. The overflow was stopped by equalizing the level between each ash pit. The NRC Senior Resident has been notified.|
|ENS 44722||15 December 2008 17:44:00||A General Licensee, a customer of Bruker AXS Handheld (Bruker) that is a device manufacturer located in Richland, Washington, returned one of Bruker's Map 4 XRF analyzers. The device had not been operating properly. When Bruker received the shipment they noticed that the package exhibited radiation levels on contact with the package of 4.9 mR/hr as measured with a GM survey instrument. This reading was unusual because it was significantly above the 0.5 mR/hr limit allowed for excepted radioactive instruments and articles transportation packaging. These packages are identified as NOS UN 2910 on the bill of lading. Bruker's receiving staff took the device to a shielded work area and when disassembled they discovered that the device's trigger mechanism was not operating properly. The mechanism did not allow the source to be fully shielded after it was released. A Bruker instrument technician discovered that one of the screws was partially backed out preventing the source block from fully closing. This screw had initially been installed per manufacturing procedure using lock-tite. This part has had no history of coming loose. The screw was replaced per the manufacturing procedure again using lock-tite on the threads as required. Bruker reported that this was the only problem like this they had experienced. The generally licensed device contained a Co-57 source, model F3-038, with a current activity of 318 megabecquerel (8.6 mCi). The source was removed and checked for contamination. None was found. The device was repaired, calibrated and sent back to the customer. Bruker has established new guidelines for their technicians when they receive a call about a device problem / malfunction. The Bruker RSO will be notified and will work directly with the customer to assess the problem prior to the device being shipped to Bruker for repair. Washington Report # - WA-08-093|
|ENS 44706||9 December 2008 13:48:00||N.C. Radiation Protection Section has confirmed the N.C. Division of Emergency Management and local law enforcement were included in initial notifications and remain engaged in the ongoing event evaluation. N.C. Radiation Protection Section was notified on 30 November 08 by an unrecorded source from UNIMIN Corporation that there was a major fire in one of their mineral processing facilities in Spruce Pine, NC. Initial reports from the licensee indicate four industrial nuclear gauges containing Cs-137 sealed sources (3 gauges contain 2 mCi each and the fourth contains 50 mCi) were present in the facility at the time of the fire. The damage to the facility exceeds $200,000 and the facility will be out of operation for over one week, so this incident is a reportable event under NC Code 15A NCAC 11.1646(a)(3) & (4). Command of the site was taken by the Bureau of Alcohol, Tobacco and Firearms (for fire investigation). Preliminary radiation surveys of the exterior of the facility indicated radiation levels equivalent to background. An inspector from N.C. Radiation Protection was dispatched to the scene on 4 December 08, but was not allowed access to the interior of the facility or to any records maintained by the RSO of UNIMIN Corporation. The inspector was allowed to examine and survey the exterior of the affected facility; he found the structural damage to be significant and that radiation levels about the perimeter of the affected facility were background. The UNIMIN RSO has been able to visually identify three of the four gauges from a vantage point exterior to the facility. Security at this facility is adequate. The investigation will be continued on 12/9 or 12/10 by the inspector from the N.C. Radiation Protection Section. North Carolina Report # NC-08-51.|
|ENS 44659||14 November 2008 09:41:00||This notification is being made due to an unplanned loss of ERDADS communication to the NRC for greater than one hour. At 0700 on November 14, 2008, the Unit 2 Control Room noted that the information from ERDADS did not appear to be updating. Notifications were made and Engineering and Operations responded to investigate. The B train of ERDADS failed at 0357 and the backup A train did not auto transfer as expected. The B train was manually failed over and the A train assumed control at 0730. The B train was rebooted and has assumed the standby position. The system is currently functioning as expected and all communications have been restored. The licensee notified the NRC Resident Inspector.|
|ENS 44635||6 November 2008 21:49:00||Nine Mile Point (NMP) Unit 1 initiated a Technical Specification (TS) shutdown at 2027. During a normal Instrumentation Surveillance Test, a relay for Emergency Condenser (ECCS) Initiation failed to meet its acceptance criteria (at 1245). This placed the plant in an action statement that required placing a channel trip in for the affected relay channel in 24 hours. To perform the relay replacement NMP Unit 1 entered 1 hour TS shutdown Limiting Condition of Operation at 1928. At 2027 Shutdown of the plant was initiated by lowering reactor recirculation flow and thus reactor power. At 2031, relay replacement was completed, (at) 2038 plant returned to full power operations. The plant remained in 24 hour action statement until post maintenance testing was completed at 2124. The licensee notified the NRC Resident Inspector.|
|ENS 44631||5 November 2008 13:23:00|
The following information was provided by the state via facsimile: The following information was reported to the Radiation Management Unit (RMU) of the Colorado Department of Public Health and Environment (CDPHE) by the acting RSO of a Colorado Licensee - Earth Engineering Consultants, Inc (EEC) - pertaining to a lost/stolen moisture density gauge. (On November 04, 2008) After taking a series of density tests of aggregate base course material for a new roadway on Jacoby Farms 5th Filing development project in Windsor, Colorado, (site location is on the north side of State Highway 392 and east 17th Street in Windsor, CO), the field technician placed gauge on his bumper, transferred the results onto his field paperwork, visited with the project supervisor and discussed the results, then entered his truck to complete additional paperwork, and received a call on his cell phone for his next project assignment. Time elapsed and the technician failed to secure the gauge back into the lock box within the pick-up truck. After realizing his dilemma, the technician immediately stopped the truck and began a search for the missing gauge. Phone calls were made to the project foreman, and an extensive search took place re-tracking the steps and paths taken. (The licensee) called the Health Department Radiation (Management Unit) and left several messages informing the state (of the missing Troxler). At approximately 11:45 AM on 11/5/08, CDPHE RMU followed up with the licensee via phone regarding the incident, at that time the licensee reported that he believed that the gauge had been recovered/found and had been dropped off at an area fire department by a member of the public last evening (11/4/08). The licensee indicated they were sending someone to the fire department to verify this and retrieve the gauge. The licensee indicated that the gauge was scratched but appeared to be intact and confirmed they would inspect the gauge and survey it. The licensee indicated that they would be sending the gauge to a local gauge repair company for leak testing and repair (as applicable). The CDPHE RMU is awaiting final confirmation/information from the licensee.
The following information was provided by the state via facsimile:
At approximately 13:15 hours (MST on 11/5/08) the Radiation Management Unit (RMU) of the Colorado Department of Public Health and Environment (CDPHE) received confirmation that the moisture density gauge lost during the evening of 11/4/08 has been recovered and is now in possession of the licensee. The gauge and its radioactive materials were out of the licensee control for less than 24 hours. During a portion of the time the gauge was missing it was in the possession of a local fire department. The CDPHE RMU does not expect any impact to any members of the public as a result of the temporarily lost gauge due to the short duration of possession.
Upon recovery, the licensee performed a visual inspection and radiological survey and has confirmed that the radioactive materials are present and intact. The gauge has been transferred to a local licensed gauge service provider where a leak test and through examination will be performed. Notified the R4DO (Campbell), FSME (Suber), and ILTAB via e-mail. 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.
|ENS 44628||4 November 2008 10:42:00|
During a routine inspection at Rocky Mountain Cancer Centers, Colorado License, two fetal overexposures were identified that had not been reported to the Department.
The first case occurred on 8/23/05, and involved a PET/CT scan where the patient was injected with 16.3 mCi of FDG (F-18). After the procedure, the patient discovered she was pregnant. The fetal exposure was estimated to be 1.5 rem. The licensee determined the risk of congenital abnormalities to be negligible. The second case occurred on 11/28/06 and also involved a PET/CT scan where the patient was injected with 11.9 mCi of FDG (F-18). After the procedure, the patient discovered she was pregnant. The fetal exposure was estimated to be 1.02 rem. The licensee determined the risk of congenital abnormalities to be negligible. No other details are available at this time. Additional information will be reported through NMED as it becomes available.
|ENS 44612||29 October 2008 22:37:00||The State of New Jersey was notified of a spill to the ground of a hazardous substance. A tube leak in a new radwaste heat exchanger caused an expansion tank to overflow resulting in less than one (1) gallon of water containing corrosion inhibiting chemicals to be discharged to the ground. The heat exchanger and the new radwaste service water system were removed from service, stopping the leak. Initial samples did not detect radioactivity in the water. Cleanup of the spill is in progress. The licensee notified the NRC Resident Inspector.|
|ENS 44603||27 October 2008 12:53:00|
At 1206 on 27 October 2008 PPL Susquehanna, LLC, declared an Alert (classification OA7) for an oxygen deficient atmosphere for a room in the Unit 2 Reactor Building. The oxygen deficient atmosphere occurred in the Unit 2 RHR Division 2 Pump Room during maintenance activities. Personnel evacuated this room. Activation of the Emergency plan is reportable under 10CFR50.72(a)(3). The licensee made all notifications as required to state and local responders. The licensee notified the NRC Resident Inspector.
The ALERT was terminated at 1726 EDT based upon re-establishment of a suitable atmosphere. The licensee notified the State, local agencies, and the NRC Resident Inspector. R1DO(Cobey), NRR EO(Giitter), and IRD(McDermott) notified. Notifications to DHS, FEMA, DOE, USDA, HHS were also made by the NRC Operations Center.
|ENS 44604||27 October 2008 16:45:00||At 1400, on 10/27/2008 CDT, the Plant Shift Superintendent was informed that EPA Region IV and the Kentucky Department of Environmental Protection had been notified of a PCB spill which occurred within the C-333 process building. This event is reportable as 'USEC shall notify NRC of any event or situation, related to the health and safety of the public or on-site personnel, or protection of the environment, for which a news release is planned or notification to other government agencies has been or will be made. Such an event may include an on-site fatality or inadvertent release of radioactively contaminated materials.' The NRC Resident Inspector has been notified of this event. PGDP Problem Report No. ATRC�08�3077: PGDP Event Report No. PAD-2008-032|
|ENS 44601||26 October 2008 15:40:00||Actuation of RPS with reactor critical. Reactor Scram occurred at 11:25, 10/26/08 from approximately 50% CTP (core thermal power). A turbine/generator trip and automatic RPS reactor scram on TCV (turbine control valve) fast closure occurred. Exact cause of turbine/generator trip is not known at this time. All withdrawn control rods fully inserted to position 00. Reactor Water Level 3 (11.4") was reached which is an RPS Scram Setpoint and also a setpoint for Group 2 (RHR to Radwaste) and Group 3 (Shutdown Cooling Isolation). No valves isolated in these systems due to their being in their normally closed position. Lowest reactor water level reached was -3" Wide Range. Appropriate off normal event procedures were entered to mitigate the transient with all systems responding as designed. No loss of offsite or ESF power occurred. No ECCS initiation signals were reached, and no ECCS or DG initiation occurred. All safety systems performed as expected. MSIVs remained open and no SRV's lifted. Main Condenser and pressure control system remained in service. Currently, reactor water level is being maintained by the condensate system in normal level band and reactor pressure is being controlled to limit cooldown. The licensee notified the NRC Resident Inspector.|
|ENS 44605||27 October 2008 19:21:00||At approximately 2342 on 10/25/2006, while performing maintenance on the solid state protection system in Mode 5 cold shutdown, Unit 2 received an automatic safety injection signal which resulted in all three ESF Diesel Generators starting and a containment ventilation isolation and containment phase A isolation. All safety injection pumps were in pull-to-lock per plant conditions so that the pumps did not start and no water was discharged into the reactor coolant system. As a result, the ESF Diesel Generators started but did not load as designed. The residual heat removal pumps were stripped from the ESF electrical busses due to the actuation. The first residual heat removal pump was restored within 4 minutes upon the loss of residual heat removal cooling and the second pump was restored within 6 minutes. The residual heat removal system heat exchangers were bypassed at the time of the event and the plant was being allowed to heat up. The cause of the automatic safety injection signal was an inadvertent removal of the block for the low pressurizer pressure safety injection system during the maintenance. Therefore, the signal was a valid signal initiated in response to a parameter satisfying the requirements for initiation of the safety function of the system. Although the actuation was the result of a valid signal, safety injection was not required in this Cold Shutdown Mode of Operation. This notification is being made under 10CFR50.72(b)(3)(iv) as an event that results in valid actuation of any of the systems listed in paragraph (b)(3)(iv)(B) of this section. This actuation was initially determined to be due to an invalid signal. Upon further review, it was determined at 1745 on 10/27/08 that the actuation was due of a valid signal. The licensee notified the NRC Resident Inspector.|
|ENS 44598||24 October 2008 00:48:00||Control Room Operators observed slight (reactor) pressure rise during panel walk down. Investigation of pressure indication led Control room staff to determine that (the) EPR (Electronic Pressure Regulator) was not functioning properly (noise in the output signal). Control Room Staff entered Special Operating Procedure for failed pressure regulator. EPR could not be moved and this was confirmed by operators in the field. Control Room Staff (then) inserted a manual scram. Immediately after the scram reactor water level reached a low of 36", Emergency Operating Procedures for Level (EOP-2) were entered. HPCI initiated on the turbine trip to control water level. After the turbine tripped, all turbine bypass valves failed open; MSIVs (main steam isolation valve) were manually shut to control pressure. (The) EPR eventually disengaged from control, allowing the operator control of the turbine bypass valves. MSIVs were then reopened. (The) Scram has been reset. (The) turbine driven shaft pump did not initially disengage, pump (was) manually tripped after turbine speed reduced to 1500 rpm. All other systems responded correctly. (The) plant is not currently in any SOPs or EOPs and is proceeding to cold shutdown using normal operating procedures. All control rods fully inserted as expected. The plant is in a normal shutdown electrical lineup. At the time of the event, containment spray loop 1-12 was out of service for routine surveillance. The plant is currently cooling down and is at 365 psi. The licensee notified the NRC Resident Inspector.|
|ENS 44588||22 October 2008 01:44:00|
On October 21, 2008, with both units operating at 100% power, Operators manually actuated the Unit 2 reactor protection system (RPS/reactor trip) due to high differential pressure (DP) across the circulating water pumps' intake traveling screens. The high DP resulted from a rapid influx of jellyfish. All systems responded as designed. All control rods fully inserted. Auxiliary feedwater actuated as designed. The grid is stable with power being supplied by 230 Kv startup power. Diesel generator (DG) 2-2 and 2-3 are operable in standby. DG 2-1 is inoperable due to scheduled maintenance. The traveling screens for the safety-related auxiliary saltwater system (ASW) are not degraded and are managing the influx of jellyfish with no significantly elevated DP. Unit 2 is stable in Mode 3 at normal operating temperature and pressure. This event is being reported in accordance with 10 CFR 50.72(b)(2)(iv)(B), 'RPS actuation,' and 50.72(b)(3)(iv)(A), 'Specified System Actuation.' Operators reduced power on Unit 1 in response to the potential loss of normal flow to the condenser due to the jellyfish influx on the traveling screens. Currently, the traveling screens are maintaining DP within limits and the unit is stable at 50% power. Unit 2 decay heat removal is being performed by Auxiliary Feed Water to four steam generators blowing down via the 10% steam dumps to atmosphere. No other safety related equipment was out of service at the time of the trip. The licensee notified the NRC Resident Inspector.
The licensee issued a press release regarding this issue. Notified R4DO (Deese).