Event Notification Report for March 1, 2007

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
02/28/2007 - 03/01/2007

** EVENT NUMBERS **


43136 43183 43188 43192 43196 43197 43198 43199 43202

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 43136
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: JAMES HUTTO
HQ OPS Officer: BILL GOTT
Notification Date: 02/01/2007
Notification Time: 00:36 [ET]
Event Date: 01/31/2007
Event Time: 18:45 [CST]
Last Update Date: 02/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
MIKE ERNSTES (R2)

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

POTENTIAL FOR PENETRATION RECIRCULATION FILTRATION SYSTEM OVERLOAD

"Due to a procedure based line-up of the Penetration Recirculation Filtration (PRF) system, it has been discovered that the system is placed in a configuration that could prevent it from performing its safety function. The PRF System filters airborne radioactive particulates from the area of the fuel pool following a fuel handling accident or ECCS pump rooms and penetration area of the Auxiliary Building following a loss of coolant accident (LOCA). The PRF system is a standby system that upon a receipt of an actuating Engineering Safety Feature Actuation System signal or upon receipt of a high radiation signal or a low air flow signal from the normal spent fuel pool room ventilation system will start the PRF fans and discharge the ventilation air stream through the system's filters.

"The standard operating procedure for the PRF system directs the control room staff to place the system in a 'full recirculation' mode of operation following a design bases LOCA if the system can maintain a proper vacuum inside the PRF boundary. The 'full recirculation' mode of operation isolates the Recirculation fan discharge to the atmosphere and fully opens the Recirculation fan recirculation damper. This mode of operation is only an additional defense in depth measure and is not credited in the accident analysis. In this mode of operation, it has been discovered that a degraded PRF boundary which allows in leakage into the boundary which is less than the maximum allowable operational limits, could place the system in a configuration that might cause the Exhaust fan to trip. The trip is caused by an overload condition at the supply breaker due to the increased flow of the Exhaust fan to the atmosphere. With the Recirculation fan discharge isolated to the atmosphere and the Exhaust fan inoperable, the PRF system may not establish an adequate vacuum in the PRF boundary during a Post LOCA accident, thus not meeting its design function.

"This condition was discovered on Unit 1, A train PRF system. Since the systems are similar between Units 1 and 2, and the procedure guidance is exactly the same for the 'full recirculation' mode of operation, this condition has the potential to affect both units, both trains of PRF.

"Corrective actions have been completed to eliminate this mode of operation from the procedure guidance given to the control room staff for operation. A major contributor to the in leakage into the PRF boundary on Unit 1 has also been repaired which reduced the running load on the Exhaust fan for that train. With the procedure guidance removed, the system should not be placed in a 'full recirculation' mode of operation, thus eliminating the potential for a failure of the designed safety function of the system."

The licensee notified the NRC Resident Inspector.

* * * UPDATE AT 1100 EST ON 2/28/07 FROM LEONARD SMITH TO S. SANDIN * * *

The licensee is retracting this event based on the following:

"This is an Update / Retraction of EN#43136IAW NUREG-1022 paragraph 4.2.3

"An eight hour report (EN #43136) per 10 CFR 50.72(b)(3)(v) was conservatively reported based on the potential of having the Penetration Room Filtration (PRF) system become inoperable during a LOCA or fuel handling event. It was believed the post accident system alignment could be relying exclusively on the PRF exhaust fan to draw negative pressure on the penetration rooms during post accident conditions. The report was generated when the FNP Unit 1 A-train PRF exhaust fan tripped while the system was being operated in the full recirculation mode, resulting in a loss of the PRF system capability to meet the intended function.

"It was concluded at that time the Post LOCA alignment of PRF could result in a similar condition since procedure guidance would have the operator place the PRF system in the full recirculation mode to enhance the cleanup function. Additional investigation, evaluation, and testing has allowed the staff to determine, due to Penetration Room Boundary (PRB) inleakage, the penetration room pressure would not meet the minimum negative pressure of -.5 in. WC in the Post LOCA alignment while in the full recirculation mode. In that case, the procedure would have the operator promptly realign the system to an acceptable configuration. Appropriate operator action would correct the system degraded condition to one that is acceptable for meeting the intended safety function. The PRF is not a fully automatic design system. Proper operation of the system in accident conditions relies on operation actions.

"In summary, the potential for loss of PRF systems necessary to fulfill the safety function of structures or systems that are needed to control the release of radioactive material or mitigate the consequences of an accident did not exist as a result of this set of conditions and the 10 CFR 50.72(b)(3)(v) report (EN #43136) is retracted."

The licensee informed the NRC Resident Inspector. Notified R2DO (Deborah Seymour).

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General Information or Other Event Number: 43183
Rep Org: OK DEQ RAD MANAGEMENT
Licensee: IPS
Region: 4
City: OKLAHOMA CITY State: OK
County:
License #: 310-0901
Agreement: Y
Docket:
NRC Notified By: MIKE BRODERICK
HQ OPS Officer: BILL GOTT
Notification Date: 02/23/2007
Notification Time: 20:43 [ET]
Event Date: 02/22/2005
Event Time: 06:00 [CST]
Last Update Date: 03/01/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM JONES (R4)
JOSEPH HOLONICH (FSME)
THOMAS BLOUNT (IRD)
CHUCK CAIN (R4)
BRUCE MALLET (R4)
LEN WERT (R4)
CHARLES MILLER (FSME)
MARTIN VIRGILIO (DEDO)
MELVYN LEACH (NSIR)
ROY ZIMMERMAN (NSIR)

Event Text

AGREEMENT STATE REPORT - MISPLACED SOURCE CAUSES POSSIBLE OVEREXPOSURE

At approximately 0600 on 2/22/07 while loading a well logging source (Gulf Nuclear CSV H90 1 Curie Cs-137 source) into the pig on the truck, the crew unknowingly dropped the source in the motor pool parking lot. The source was picked up by a mechanic at approximately 0900 and he put it in the pocket of his jacket. He did not realize that it was radioactive, but thought it might be a part to something. The mechanic wore the jacket for about 4 hours. He visited several businesses including a sandwich shop. He hung the jacket in the break room where it remained for the remainder of the day and over night. On 02/23/07, the mechanic put the jacket back on. The well logging crew returned to the facility at approximately 0600 and discovered that the source was missing when they unpacked their equipment. The crew did not discover the missing source earlier because they did not need to use the source on a job site. The crew immediately started a search for the source. The mechanic produced the source when he heard that it was missing. In total the mechanic wore the jacket about 5.5 hours over the 24 hour period. This is an estimate based on an interview with the mechanic who was uncertain about the exactness of his recollection for the time he wore the jacket.

The mechanic and a couple of coworkers were taken to a local hospital emergency room and examined. No abnormalities were noted. They are scheduled to return to the emergency room on 2/24/07. Oklahoma continues to investigate. There has been no media interest.

The R4 PAO (V. Dricks) was also notified.

* * * UPDATE ON 02/24/07 AT 1025 EST BY MIKE BRODERICK TO MACKINNON * * *

Patient received two white blood cell counts, one on 02/23 and the other on 02/24, at Integris Baptist Hospital, Oklahoma City, Oklahoma, and both white blood cell counts were normal. The Doctor does not think the patient received a large dose. Patient is to report back in 1 week for follow-up testing.

A blood sample of the patient will be sent to RPA located in London, England for chromosome analysis.

R4DO ( Bill Jones) and NMSS EO (Joe Holonich) notified.

* * * UPDATE ON 02/24/07 AT 1228 EST BY MIKE BRODERICK TO W. GOTT * * *

The patient visited the hospital emergency room again on 2/24/07. The ER Physician stated there was no sign of radiation effects. Oklahoma is arranging for the exposed individual to see a radiologist and/or oncologist at the OU Health Sciences Center. Blood samples will be drawn and provided to RPA in the UK for chromosome analysis. The state investigation is continuing.

R4DO ( Bill Jones) and NMSS EO (Joe Holonich) notified.

* * * UPDATE ON 02/26/07 AT 1117 EST BY MIKE BRODERICK TO P. SNYDER * * *

The state provided a matrix of dose rate readings taken around the source by the licensee. The state is evaluating the information. The NRC continues to interface with the state on this event.

Notified R4 (C. Cain), R4DO (D. Powers) and NMSS EO (S. Wastler).

* * * UPDATE ON 02/26/07 AT 1255 EST BY MIKE BRODERICK TO J. KNOKE * * *

"When the mechanic removed the jacket containing the source, he initially hung it on a bollard (cement & metal post to keep vehicles away from a building) outside the logging company office. It was there all afternoon, the assistant mechanic stated that he was working in that area, so he has the possibility for exposure. The mechanic who was the main exposed person moved the jacket to the company break room at quitting time. There were staff working around the clock Thursday night, so there is a definite possibility staff were near the jacket while it was hanging there. Fortunately, the break room is small (more like a large closet) so most likely they would have gotten coffee and left. We will be interviewing staff this afternoon to try to nail this down."

"The exposed individual will see a very well-qualified physician, this afternoon. DEQ staff asked him to sign medical releases authorizing release to DEQ and to NRC. A blood sample will be taken and shipped to England for chromosome analysis.

"DEQ staff will be doing interviews this afternoon with facility staff who were potentially exposed to the source. DEQ staff will use this information to determine who else may warrant medical follow-up. We will also get confirmatory readings on the radiation level of the source with an ion chamber (as opposed to the GM tubes used by the company measures sent earlier).

Notified R4 (C. Cain) Email only, R4DO (D. Powers) and NMSS EO (S. Wastler).

* * * UPDATE ON 02/26/07 AT 1908 EST BY MIKE BRODERICK TO W GOTT * * *

"The primary exposed individual ('A') has been seen by a physician from the OU Health Sciences Center who has strong radiation protection credentials. The physician's belief is that the patient will probably suffer radiation burns on his abdomen, and possibly on his fingertips. He doesn't expect any other short-term effects. No burns or other effects are visible now. There is no sign of GI tract syndrome. 'A' is going to have follow-up visits with the physician at one week and two weeks, and possibly additional visits.

"A blood sample has been taken from 'A' and tomorrow it will be shipped to England for chromosome analysis. There was some delay due to international shipping requirements for biohazardous material.

"DEQ and OU HSC staff worked together this afternoon to take measurements using ion chambers. The measurements showed lower readings than those calculated through inverse square law. We will prepare a detailed report tomorrow and send it. In short, the dose level with the ion chamber case in contact with the source was 3.3 rem/hour, falling off to 139 mrem/hour at one meter. A badge was exposed to the source at one inch for 3 minutes 35 seconds, and is being sent to Landauer for emergency processing, which will give us more information.

"DEQ staff interviewed additional personnel at the licensee this afternoon, focusing on determining who might have been exposed to excess dose other than 'A.' Tentatively, the most at-risk individual appears to be a coworker who rode with 'A' to lunch. While they were in the cab of a pickup truck, the coworker was sitting in the passenger seat on the opposite side of 'A's' body from the source, and across a sandwich shop booth from 'A' during lunch. After lunch, 'A' and the coworker worked together on a logging truck with the coat (and source) hanging a couple of yards away. They spent most of their time under the truck, which would have provided considerable shielding. Tentatively we think it is conceivable the coworker broke the limit for dose to the public, but doubt there was medically significant exposure. We will do a detailed analysis tomorrow to test this."

Notified R4DO (D. Powers) and FSME EO (J. Holonich)

* * * UPDATE PROVIDED BY MIKE BRODERICK TO JEFF ROTTON VIA EMAIL AT 1723 EST ON 02/27/07 * * *

"The results for the dosimeter that was exposed to the Cesium source at one inch for 3 minutes 35 seconds were reported from Landauer this afternoon. Deep dose was 16,106 mrem and shallow dose was 15,374 mrem. This works out to about 4.4 R/minute or 264 R/hour skin dose.

"The package containing the blood sample from 'A' was shipped to England via overnight delivery this afternoon. Results are expected in the first half of next week."

The results of the examination of 'A' by an OUHSC radiologist have been received and will be combined with the ER records from the weekend and faxed to the NRC on 02/28/07. The results were not substantially different from the verbal report on 02/26/07 and described in the update on the afternoon of 02/26/07.

Notified R4DO (Powers) and FSME EO (Mohseni).


* * * UPDATE PROVIDED BY MIKE BRODERICK TO BILL HUFFMAN AT 0030 EST ON 03/01/07 * * *

OK DEQ provided corrections to the previous report information. Specifically, the well logging source was originally reported to be a directional source. DEQ states that the source was not a directional source. In addition, the update on 2/27/07 reported a dose rate of 4.4 mrem/minute. This should have been 4.4 Rem/minute. The text of the previous report information has been corrected accordingly.

Notified R4DO (Powers) and FSME EO (Davis).

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General Information or Other Event Number: 43188
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: SOUTHWEST RESEARCH INSTITUTE
Region: 4
City: SAN ANTONIO State: TX
County:
License #: L00775
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/26/2007
Notification Time: 15:31 [ET]
Event Date: 02/26/2007
Event Time: [CST]
Last Update Date: 02/27/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
SANDRA WASTLER (NMSS)
DALE POWERS (EMAIL) (R4)

This material event contains a "Category 1" level of radioactive material.

Event Text

AGREEMENT STATE REPORT

"On 2/26/07 at about 13:30 the licensee notified the Agency that they had received 8 sources from White Sands Missile Base containing cobalt sixty (Co-60) sources. Four were estimated to have activities of 3,000 curies and four had estimated activities of 1,000 curies. Southwest opened one of the containers used to ship the sources to leak test the source. Upon opening the container, it appeared that the source was no longer contained in a source capsule. The leak test results indicated 5 million DPM. The container was resealed and no other containers were opened."

Containers were opened with automation equipment, therefore no exposure to personnel occurred.

TX Report TX-07-43188


* * * UDPATE ON 02/27/07 AT 0950 EST FROM ARTHUR TUCKER VIA E-MAIL TO MACKINNON * * *

"On 2/26/07 at about 11:00 the licensee notified the Agency that they had received eight (8) cobalt sixty sources from White Sands Missile Range. Each of the eight sources was contained in a separate container. Four sources had estimated activities of 3,000 curies and four had estimated activities of 1,000 curies. The outside of each container was surveyed after receipt and contamination levels were found to be below their limits. SWR opened one of the containers used to ship the sources to leak test the source. The source was a Neutron Products Inc. model no. NPU-25-13000 capsule serial # T-96-5. The container was opened in SWR hot cell using manipulator arms. Upon opening the source container, it appeared that the source capsule had been breached. The leak test results indicated 5 E6 dpm of contamination. The container was sealed and no other sources were opened. The sources were removed from the hot cell. The hot cell was surveyed and found to be contaminated. The hot cell was decontaminated and returned to service.

R4DO (Dale Powers) & NMSS EO (Greg Morell) notified.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 1" LEVEL OF RADIOACTIVE MATERIAL

Category 1 sources, if not safely managed or securely protected would be likely to cause permanent injury to a person who handled them, or were otherwise in contact with them, for more than a few minutes. It would probably be fatal to be close to this amount of unshielded material for a period of a few minutes to an hour. These sources are typically used in practices such as radio thermal generators, irradiators and radiation teletherapy.

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General Information or Other Event Number: 43192
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: AKRON GENERAL MEDICAL CENTER
Region: 3
City: AKRON State: OH
County:
License #: 02120-78-0000
Agreement: Y
Docket:
NRC Notified By: MARK LIGHT
HQ OPS Officer: JEFF ROTTON
Notification Date: 02/27/2007
Notification Time: 14:04 [ET]
Event Date: 09/27/2006
Event Time: [EST]
Last Update Date: 02/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ROGER LANKSBURY (R3)
GREG MORELL (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL MEDICAL EVENT

At 1405 EST on 02/26/07, the state received a report via the US Mail from Akron General Medical Center. On 09/27/06 a patient was receiving a 10 fraction dose for Mammo-site Breast Brachytherapy using a HDR afterloader with a total prescribed dose of 3400 RAD. A problem with the PLATO planning computer digitized the breast image using an incorrect treatment factor which doubled the fractional dose. The same total prescribed dose was delivered but in 5 vice 10 fractional doses. The patient was made aware of the error on 09/27/06. Tissue necrosis was observed due to the procedure, but it is being evaluated if any additional necrosis occurred due to the delivery of the total dose in 5 fractions vice the 10 planned fractional doses. The licensee is taking corrective action to prevent a reoccurrence of this type of error.

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.

*** UPDATE FROM FSME (FLANNERY) TO KNOKE ON 02/28/07 ***

This event has been reviewed and determined to be a reportable medical event.

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Power Reactor Event Number: 43196
Facility: KEWAUNEE
Region: 3 State: WI
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP
NRC Notified By: AL PROKASH
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/28/2007
Notification Time: 02:04 [ET]
Event Date: 02/27/2007
Event Time: 23:33 [CST]
Last Update Date: 02/28/2007
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):
ROGER LANKSBURY (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 100 Power Operation 0 Hot Shutdown

Event Text

REACTOR TRIP DURING THE PERFORMANCE OF A SURVEILLANCE

"On 2/27/2007 at 2333 CST a Reactor Trip occurred during performance of a surveillance procedure calibrating a Nuclear Power Range instrument. The Reactor trip resulted in an automatic Turbine Trip and actuation of the Auxiliary Feedwater System. No safeguards equipment was out of service at the time of the trip. Following the trip, a steam inlet valve on a Moisture Separator associated with the main turbine failed to close which resulted in RCS temperature decreasing to 537 degF. This valve was manually isolated and RCS temperature returned to normal 547 degF. Normal heat sink to the Main Condenser was available during the event. Investigation is continuing into the exact cause of the Reactor trip.

"This event is being reported under 10CFR50.72(b)(2)(iv)(B) for actuation of the Reactor Protection System and 10CFR50.72(b)(3)(iv)(A) for actuation of the Auxiliary Feedwater System."

All control rods fully inserted on the reactor trip. Decay heat is being removed by Auxiliary Feedwater feeding the steam generators, steaming to the main condenser.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43197
Facility: BRUNSWICK
Region: 2 State: NC
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE JESTER
HQ OPS Officer: PETE SNYDER
Notification Date: 02/28/2007
Notification Time: 05:40 [ET]
Event Date: 02/27/2007
Event Time: 22:26 [EST]
Last Update Date: 02/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DEBORAH SEYMOUR (R2)

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

Event Text

HIGH PRESSURE COOLANT INJECTION (HPCI) INOPERABILITY

"On February 27, 2007, at approximately 2200 hours, testing of the Unit 2 High Pressure Coolant Injection (HPCI) system was in progress in accordance with 0PT-09.2, HPCI System Operability Test following system maintenance. Soon after the HPCI turbine was started a high level alarm condition in the HPCI barometric condenser was experienced. Evidence suggests the most probable cause was due to failure of the 2-E41-F048, Condensate Pump Discharge Check Valve, to open. The adverse consequence of this check valve failing to open is inadequate cooling flow to the HPCI lube oil cooler. The HPCI turbine was removed from service per applicable plant procedures.

"At the time of discovery, the HPCI system was inoperable for scheduled maintenance. However, this equipment failure would have prevented the HPCI system from fulfilling its safety function. Limiting Condition for Operation (LCO) per Technical Specifications (TS) 3.5.1. 'ECCS - Operating' Condition D had been previously entered on 2/25/07 at 1500, which required maintaining the Reactor Core Isolation Cooling (RCIC) system operable and restoration of HPCI operability in 14 days.

All other ECCS systems are operable including RCIC. The LCO allowed outage time is due to expire on 3/11/07 at approximately 1500 hours.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43198
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: DAVE BOWMAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 02/28/2007
Notification Time: 05:53 [ET]
Event Date: 02/28/2007
Event Time: 01:20 [CST]
Last Update Date: 02/28/2007
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):
ROGER LANKSBURY (R3)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 30 Power Operation 0 Hot Shutdown

Event Text

UNIT 2 REACTOR MANUALLY SCRAMMED DUE TO DECREASING CONDENSER VACUUM

"At 0120 hours on February 28, 2007 the Unit 2 Reactor was manually scrammed due to decreasing condenser vacuum. All control rods fully inserted during the scram. Reactor water level decreased to approximately -10", which resulted in automatic Group II and III isolations as expected. All systems responded properly to the event. Unit 2 remains in Mode 3, maintaining reactor pressure, with reactor water level in the normal level band. The cause of this event is still under investigation.

"Unit 1 was unaffected by the event and remains at 97% power.

"This report is being made in accordance with 10CFR50.72 (b)(2)(iv)(B) and 10CFR50.72 (b)(3)(iv)(A)."

The Main Condenser remains in service removing decay heat via the bypass valves. All ECCS equipment is available, if needed.

The licensee will inform the State and has informed the NRC Resident Inspector.

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Power Reactor Event Number: 43199
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: DAN LYON
HQ OPS Officer: PETE SNYDER
Notification Date: 02/28/2007
Notification Time: 10:01 [ET]
Event Date: 02/28/2007
Event Time: 06:35 [EST]
Last Update Date: 02/28/2007
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):
JOHN ROGGE (R1)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 100 Power Operation 0 Hot Standby

Event Text

MANUAL REACTOR TRIP FOLLOWING MALFUNCTION OF PRESSURE TRANSMITTER

"At approximately 0633 AM on February 28, 2007, control room operators manually initiated a reactor trip after observing decreasing steam generator levels as a result of low feed water flow. Control room alarms indicated low main feed water pump suction pressure which was subsequently, attributed to a malfunction of the main feed water pump low suction pressure cutback pressure transmitter (PT-408B) on the common main feed pump water supply header. The malfunction of the main feed pump water low suction cutback pressure transmitter resulted in a cutback of both main feed water pumps reducing main feed water flow to the steam generators and causing decreasing steam generator levels.

"All control rods fully inserted and all safety systems responded as expected. The auxiliary feedwater system actuated as expected from low steam generator levels which occurs as a result of a full power reactor trip. The emergency diesel generators (EDGs) did not start as offsite power remained available. The plant was stabilized in hot shutdown with the [Auxiliary Feedwater System] providing decay heat removal via the main condenser. The main feed water pumps are shutoff and secured.

"The event is under investigation and a post trip review is being conducted. A courtesy call to stakeholders will be made."

All EDGs remain available in standby. No steam generator Power Operated Relief Valves or Main Steam Safety Valves lifted.

The licensee notified state and will notify local authorities. The licensee plans to issue a press release. The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 43202
Facility: ZION
Region: 3 State: IL
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: ARTHUR ADAMS
HQ OPS Officer: JOHN KNOKE
Notification Date: 02/28/2007
Notification Time: 14:16 [ET]
Event Date: 02/28/2007
Event Time: 13:05 [CST]
Last Update Date: 02/28/2007
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(ii) - LOST/STOLEN LNM>10X
Person (Organization):
ROGER LANKSBURY (R3)
GREG MORELL (FSME)
This material event contains a "Less than Cat 3" level of radioactive material.

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Decommissioned 0 Decommissioned
2 N N 0 Decommissioned 0 Decommissioned

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

Event Text

EXTREMELY SMALL AMOUNT OF SNM UNACCOUNTED FOR


"This is a non-emergency event notification in accordance with 10 CFR 20.2201(a)(1)(ii) to report an accountability discrepancy of licensed material.

"In the process of reviewing records, it was identified that all disposition records for reactor incore detectors could not be found. The reactor incore detectors contain very small quantities of U-235 and were used to monitor reactor power at Zion Station from 1972 to 1988.

"The unaccounted for material was classified as missing on February 28, 2007 due to lack of records documenting the current location of the detectors; however, based on available records and discussions with former Zion Nuclear Material Custodians, it is believed that these detectors were shipped as radioactive waste to the Barnwell Low-Level Radioactive Waste Disposal Facility located in South Carolina. A search of storage locations at Zion was performed, but the detectors have not been located.

"Historical records indicate that it was common practice for Zion Station to dispose of detectors in this manner. There is no evidence of theft or diversion of these detectors. The incomplete records involve 43 incore detectors received onsite prior to 1988. The detectors contain an extremely small amount of Special Nuclear Material and pose no significant safety concern. Depending on design, each incore detector contained between 0.0025 grams to 0.0004 grams of Uranium 235 resulting in an aggregate quantity of approximately 0.102 grams of Uranium 235. The activity of this quantity is approximately 0.22 microcuries. This quantity is greater than the reportability threshold of 10 times the quantity specified in Appendix C to 10 CFR 20 which is 0.01 microcuries.

"A subsequent written report will be made in accordance with 10 CFR 20.2201(b)."

The licensee will notify the NRC Resident Inspector and the State.


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

Page Last Reviewed/Updated Wednesday, March 24, 2021