United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for February 1, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/31/2011 - 02/01/2011

** EVENT NUMBERS **


46021 46572 46576

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 46021
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JAMES E. MURAIDA
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/17/2010
Notification Time: 14:15 [ET]
Event Date: 06/17/2010
Event Time: 05:19 [CDT]
Last Update Date: 02/01/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

UNANALYZED CONDITION DUE TO CONTAINMENT SPRAY RECIRC SUMP ISOLATION VALVE FAILURE TO STROKE CLOSED

"At 0519 CDT on June 17th, Unit 2 was closing the 2CS009B, Containment Spray Recirc Sump Isolation Valve, as part of post maintenance testing when the valve stopped stroking (i.e. mid position). The 2CS009B valve was being stroked closed for restoration from a successful timed stroke in the open direction. The 2CS009B valve was manually closed and verified closed via limit switch indication.

"With the 2CS009B valve unable to be closed from the Main Control Room, an unanalyzed condition may have existed where, during a large break LOCA requiring cold leg recirc, the Refueling Water Storage Tank (RWST) had an additional flow path to the containment recirc sump. This potentially challenges the operators to complete the switchover prior to the RWST reaching 9%, the point at which pumps taking a suction from the RWST only are shutdown. This condition is still being evaluated."

The licensee notified the NRC Resident Inspector.

* * * RETRACTION FROM P. MOODY TO P. SNYDER AT 0404 ON 2/1/11 * * *

"At 0509 on June 17, 2010, Unit 2 was closing the 2CS009B, Containment Spray (CS) Recirculation Sump Isolation Valve, as part of post maintenance testing when the valve stopped stroking (i.e., mid-position). The 2CS009B was being stroked closed for restoration from a successful timed stroke in the open direction. The 2CS009B was manually closed and verified closed via limit switch indication.

"With the 2CS009B unable to close from the Main Control Room, an unanalyzed condition may have existed where, during a large break LOCA requiring cold leg recirculation, the Refueling Water Storage Tank (RWST) had an additional flow path to the recirculation sump. This potentially challenged the operators to complete the switchover prior to the RWST reaching 9%, the point at which pumps taking a suction from the RWST only are shutdown. While this condition was being evaluated, an ENS notification was made per ENS 46021 under 10CFR50.72(b)(3)(ii)(B).

"As the evaluation approached the 60-day reporting period, LER 2010-002 was issued in accordance with 10 CFR 50.73(a)(2)(ii)(B), assuming the results would yield an unanalyzed condition.

"Since then, an evaluation was completed. The results concluded the operators would have performed the switchover steps within the allowed time, before reaching the RWST empty alarm set point. Therefore, the Emergency Core Cooling System (ECCS) and CS system would have performed their design functions. The evaluation also determined the RWST outflows with 2CS009B in the open position during the ECCS switchover sequence did not affect the RWST vortex analysis. Based on no loss of design function, the plant was not in an unanalyzed condition and this event is not reportable per 10CFR 50.72(b)(3)(ii)(B) or 10CFR 50.73(a)(2)(ii)(B). This event was screened for additional reportability criteria contained in the Exelon Reportability Manual. Again, since there was no loss of design function there is no reportability requirement.

"Therefore ENS notification 46021 is being retracted."

The licensee notified the NRC Resident Inspector.

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Agreement State Event Number: 46572
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: CLEVELAND CLINIC FOUNDATION
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180013
Agreement: Y
Docket:
NRC Notified By: STEPHEN JAMES
HQ OPS Officer: DONG HWA PARK
Notification Date: 01/26/2011
Notification Time: 10:14 [ET]
Event Date: 12/08/2010
Event Time: [EST]
Last Update Date: 01/26/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
DAVID HILLS (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - POTENTIAL UNDERDOSE TO PATIENT DUE TO ABORTED TREATMENT

The following information was received from the State of Ohio by email:

"Written directive called for Iodine-125 radioactive seed implant of the prostate with 142 seeds, 0.477 mCi each, total activity 67.7 mCi. Transperineal implantation of the needles were attempted on 12/8/10. After placement of four needles (8 sources) in the first (anterior-most) row, it was subsequently noted that patient's pelvic inlet was too narrow for adequate placement of the lateral two columns of seeds after repeated attempts. Authorized User Physician decided to abort procedure at this point. Patient was taken to the recovery room in satisfactory condition. Patient was notified at time of event. Radiation Safety Officer was not notified at time of event.

"Licensee's RSO discovered event during QMP review on morning of 1/25/11 and notified ODH [Ohio Department of Health] by telephone and e-mail that afternoon. ODH inspector will visit licensee's location on 1/31/11.

"Given: Radionuclide: I-125; Activity: 3.2 mCi (118.4 MBq); Dose: 81.1 rad (0.811 Gy).
"Intended: Radionuclide: I-125; Activity: 67.7 mCi (2504.9 MBq); Dose: 14400 rad (144 Gy)."

The source used was a Brachytherapy sealed source I-125; Model Number STM-1251; Serial Number 2357321SO; Activity .477 Ci (17.649 GBq).

Ohio number: OH110001

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

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Power Reactor Event Number: 46576
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: SCOTT WISE
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 01/31/2011
Notification Time: 10:14 [ET]
Event Date: 01/31/2011
Event Time: 08:49 [EST]
Last Update Date: 01/31/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
RICHARD SKOKOWSKI (R3DO)

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

Event Text

EMERGENCY NOTIFICATION SYSTEM SIRENS INADVERTANTLY ACTUATED FOR 3 MINUTES

"At 0849 [EST] on 1/31/2011 the Emergency Notification System Sirens inadvertently actuated for 3 minutes. We [Davis Besse] have been informed by Ottawa county that the actuation signal appears to have originated from the Ottawa County Sherriff's dispatcher console. They also informed Davis Besse that Vendor Support is being requested to assist in the determination of the cause. The Ottawa County Emergency Management Agency is planning a news release for the inadvertent actuation."

The Emergency Notification System sirens were secured and are considered to be operable. The licensee notified the NRC Resident Inspector.

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