Event Notification Report for May 23, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
05/20/2011 - 05/23/2011

** EVENT NUMBERS **


46853 46854 46855 46866 46868 46870 46872

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Fuel Cycle Facility Event Number: 46853
Facility: PADUCAH GASEOUS DIFFUSION PLANT
RX Type: URANIUM ENRICHMENT FACILITY
Comments: 2 DEMOCRACY CENTER
                   6903 ROCKLEDGE DRIVE
                   BETHESDA, MD 20817 (301)564-3200
Region: 2
City: PADUCAH State: KY
County: McCRACKEN
License #: GDP-1
Agreement: Y
Docket: 0707001
NRC Notified By: DEREK WARFORD
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/15/2011
Notification Time: 21:39 [ET]
Event Date: 05/15/2011
Event Time: 12:54 [CDT]
Last Update Date: 05/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
76.120(c)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
EUGENE GUTHRIE (R2DO)
BRITTAIN HILL (NMSS)

Event Text

PORTION OF HIGH PRESSURE FIRE WATER SYSTEM DECLARED INOPERABLE

"At 1254 CDT, on 05/15/2011, the Plant Shift Superintendent was notified that the C-333 High Pressure Fire Water (HPFW) Sprinkler System C-14 had been inspected by Fire Services and eleven sprinkler heads had visible corrosion on them. The system configuration was evaluated using EN-C-822-99-047, 'Effects of Impaired Sprinkler Heads on System Operability' and determined that with these heads potentially impaired, a portion of the building would not have sufficient sprinkler coverage. The HPFW system is required to be operable according to TSR LCO 2.4.4.5. HPFW system C-14 was declared inoperable and TSR LCO 2.4.4.5 Required Action B was implemented for the area without sprinkler coverage. Based on past testing results, there is a possibility that the heads would have been able to perform their specified safety function. Once the heads are removed from the system, testing will be performed to determine the actual affect on operability.

"This event is reportable under 10 CFR 76.120(c)(2) as an event in which equipment required by the TSR is disabled or fails to function as designed.

"The NRC Senior Resident Inspector has been notified of this event.

"PGDP [Paducah Gaseous Diffusion Plant] Assessment and Tracking Report No. ATR-11-1192; PGDP Event Report No. PAD-2011-08; Responsible Division: Operations

"An hourly fire patrol is being conducted in the affected area. [Licensee] estimated correction date: 5/20/2011."

* * * RETRACTION FROM BILLY WALLACE TO JOE O'HARA AT 1145 EDT ON 5/20/11 * * *

"Subsequent to the event, the corroded sprinkler heads were replaced with new heads and the removed heads were tested in the laboratory. Testing by the laboratory has shown that six of the 10 removed sprinkler heads would have performed their safety function, five of the heads would not have performed their safety function, but these heads would not affect the system operability. The conclusion of the tests is that the C-333 sprinkler system C-14 would have performed its intended safety function if called upon.

"The NRC Senior Resident Inspector has been notified of this retraction."

Notified R2DO(Shaeffer) and NMSS EO(Damon)

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Hospital Event Number: 46854
Rep Org: LANTHEUS MEDICAL IMAGING
Licensee: LANTHEUS MEDICAL IMAGING
Region: 1
City: SAN JUAN State: PR
County:
License #:
Agreement: N
Docket:
NRC Notified By: EDWARDO DIAZ
HQ OPS Officer: DONG HWA PARK
Notification Date: 05/16/2011
Notification Time: 14:09 [ET]
Event Date: 05/13/2011
Event Time: 12:00 [EDT]
Last Update Date: 05/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
MEL GRAY (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT - WRONG RADIOPHARMACEUTICAL ADMINISTERED TO PATIENT

On 5/13/2011, a patient at the Lantheus Medical Imaging center was administered Indium 111 (Oxine - for labeling white blood cells) instead of Indium 111 (DTPA - for brain study), which was the prescribed radiopharmaceutical. Less than 1 milliCurie of Indium 111 (Oxine) was injected into the patient. The dose received by the patient was less than 5 Rem, and no injury was caused to the patient.

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.

* * * RETRACTION ON 5/17/11 AT 0939 FROM EDWARDO DIAZ TO MARK ABRAMOVITZ * * *

This event has been determined by the licensee not to be a medical event because the total dose is less than 0.05 Sv (5 Rem) required in 10CFR35.3045.

Notified the R1DO (Gray) and FSME (McIntosh).

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Agreement State Event Number: 46855
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: LOWELL GENERAL HOSPITAL
Region: 1
City: LOWELL State: MA
County:
License #: 44-0060
Agreement: Y
Docket:
NRC Notified By: KENATH O. TRAEGDE
HQ OPS Officer: PETE SNYDER
Notification Date: 05/17/2011
Notification Time: 14:14 [ET]
Event Date: 02/16/2011
Event Time: [EDT]
Last Update Date: 05/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MEL GRAY (R1DO)
CHRISTIAN EINBERG (FSME)

Event Text

AGREEMENT STATE REPORT - DOSE TO FETUS DURING THYROID SCAN

The following report was received from the state via fax:

"A patient having a thyroid scan was administered 4 mCi of I-131 while in a pregnant condition. The circumstances under which the dose was administered are under investigation. The dose to the developing fetus is also under investigation. The whole body dose to the fetus is estimated to be 1 rad at this time.

"The discovery date [of 4/15/11] is an estimate. The real dose of discovery will be reported during the investigation. Also, the licensee was allowed 15 working days to issue a report to [the Massachusetts Radiation Control Program]. [The Massachusetts Radiation Control Program] received that report on May 12, 2011."

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Power Reactor Event Number: 46866
Facility: SURRY
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: CURTIS LYCKE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/20/2011
Notification Time: 13:23 [ET]
Event Date: 05/20/2011
Event Time: 12:00 [EDT]
Last Update Date: 05/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
SCOTT SHAEFFER (R2DO)

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 N 0 Refueling Shutdown 0 Refueling Shutdown

Event Text

MEDIA CONCERN ABOUT BOAT NEAR THE SITE

"On 05/20/2011 at approximately 0728, an unidentified man was reported to be floating on a raft in the James River offshore of the Hog Island Wildlife Management Area. The individual had chains wrapped around his body and a suitcase and duffel bag in the raft. Station Security responded to facilitate local law enforcement actions. The individual in the raft was pulled to the shore and taken into custody. At no time was the operation of Surry Power Station threatened by the man's actions.

"The site NRC Resident Inspector has been notified.

"This notification is being transmitted in accordance with 10CFR50.72(b)(2)(xi) to ensure that the NRC is made aware of issues that may cause heightened public concern for the safety of the station."

The man was approximately a mile offshore during this incident.

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Power Reactor Event Number: 46868
Facility: BRAIDWOOD
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: PETER MOODIE
HQ OPS Officer: JOE O'HARA
Notification Date: 05/20/2011
Notification Time: 22:57 [ET]
Event Date: 05/20/2011
Event Time: 18:00 [CDT]
Last Update Date: 05/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
JULIO LARA (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 MARINE LIFE INSIDE AFW PIPING

"The past operability of the 2A train of Auxiliary Feedwater has been called into question based on finding clam shells in the safety related water source piping. During performance of valve strokes on 5/9/2011 per an Operations Department surveillance, clam shells were found while draining a section of the safety related water source piping. System Engineering collected the shells as part of troubleshooting. Based on analysis performed by System Engineering, the 2A Train of Auxiliary Feedwater was not operable with clam shells in the pipe. The amount of shells present would have caused an unacceptable differential pressure across the 2A train Auxiliary Feedwater System flow control valves. The extent of condition has been evaluated for the other Auxiliary Feedwater trains for both units and it has been determined that the only affected train is 2A. The 2B Auxiliary Feedwater train has also been inoperable at various times over the past 3 years for maintenance.

"The clams were flushed out of the 2A Train Auxiliary Feedwater suction piping during a recent refueling outage and both trains of Auxiliary Feedwater on Unit 2 are operable. "

The licensee has not implemented any compensatory measures nor are they in any LCO's as a result this event.

The NRC Resident Inspector has been notified.

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Power Reactor Event Number: 46870
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: DAVID HALL
HQ OPS Officer: BILL HUFFMAN
Notification Date: 05/21/2011
Notification Time: 01:56 [ET]
Event Date: 05/20/2011
Event Time: 22:17 [CDT]
Last Update Date: 05/21/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
SCOTT SHAEFFER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 22 Power Operation 22 Power Operation

Event Text

HPCI CHECK VALVE LEAKAGE RESULTS IN SYSTEM LEAKAGE DURING MAINTENANCE

"On 5/20/2011 at 2217 [CDT], while performing 1-SR-3.5.1.1(HPCI) MAINTENANCE OF FILLED HPCI DISCHARGE PIPING, operators opened 1-FCV-73-44, HPCI Injection Valve, to fill and vent portions of the system. Once open, the HPCI discharge piping rapidly pressurized to 1000 psig. Operators immediately shut the 1-FCV-73-44 valve. A flood level alarm was received in the control room and water was confirmed to have been leaking from the Gland Seal Condenser. All leakage has stopped.

"It is suspected that leakage past 1-CKV-73-45, HPCI TESTABLE CHECK VALVE, caused the rise in discharge piping pressure. An investigation into this event is ongoing.

"In accordance with TS LCO 3.6.1.3 Condition A, the affected line has been isolated by one closed and deactivated valve.

"This incident is reportable as an 8-hour ENS notification under 10CFR 50.72 (b)(3)(v) as 'any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to: d. Mitigate the consequences of an accident.'

"It also requires a 60 day written report in accordance with 10CFR 50.73(a)(2)(vii). The NRC Resident Inspector has been notified."

The volume of leakage was not specifically known but the leakage resulted in approximately 2 inches of water on the HPCI pump room floor before it was isolated.

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Power Reactor Event Number: 46872
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [ ] [ ] [3]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: TIM TAYLOR
HQ OPS Officer: JOE O'HARA
Notification Date: 05/22/2011
Notification Time: 22:34 [ET]
Event Date: 05/22/2011
Event Time: 17:37 [CDT]
Last Update Date: 05/22/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
SCOTT SHAEFFER (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

VALID REACTOR PROTECTION SYSTEM (RPS) ACTUATION SIGNAL - SCRAM DISCHARGE VOLUME (SDV) HIGH WATER LEVEL

"At 1737 CDT on 05/22/2011, with BFN U3 [Browns Ferry Unit 3] in Mode 4, a valid RPS actuation signal was received by both channels of the RPS due to Scram Discharge Volume (SDV) High Water Level.

"At 1735, while performing IRM range 6 to 7 correlation, Instrument Maintenance technicians were measuring high voltage on IRM 'G' while reconnecting a high voltage cable. A spike occurred on IRM's 'C' and 'D' causing a full Reactor Scram. This IRM [Intermediate Range Monitor] Scram was not a valid actuation, the safety function had already been completed, and is not reportable. At 1737, after diagnosing the cause of the IRM Scram, operators reset the Scram signal and received a valid RPS Scram signal due to SDV High Water Level. Investigation is ongoing.

"This condition is reportable under 10CFR50.72(b)(3)(iv)(A) - A valid actuation of any of the systems named in 50.72(b)(3)(iv)(B).

"This is also reportable as 60 day written report IAW 10CFR 50.73(a)(2)(iv)(A).

"This event was entered into the licensee's Corrective Action Program as SR# 373366."

There are no compensatory measures or LCO's in effect for this event, and all EDG's and offsite power lines are operable. There was no increase in plant risk as a result of this event.

The NRC Resident Inspector has been notified.

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