United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for August 22, 2011

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/19/2011 - 08/22/2011

** EVENT NUMBERS **


47158 47159 47163 47169 47170 47171 47172 47176 47177

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Non-Agreement State Event Number: 47158
Rep Org: CHRISTIANA CARE
Licensee: CHRISTIANA CARE
Region: 1
City: NEWARK State: DE
County:
License #: 0712153-02
Agreement: N
Docket:
NRC Notified By: JOSEPH SOLGE
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/16/2011
Notification Time: 14:47 [ET]
Event Date: 08/09/2011
Event Time: [EDT]
Last Update Date: 08/16/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)

Event Text

DOSE DIFFERENT THAN PRESCRIBED

A patient was scheduled to receive three separate treatments for pancreatic cancer containing Yttrium-90. Each dose was to contain 10.5 milliCuries of Yttrium-90 for a total of 31.5 milliCuries. Cardinal Health (the producer of the treatment) provided the entire dose of 31.5 milliCurie in a single syringe. The physician verified the receipt of the syringe and administered it to the patient.

When the patient was scheduled to return on 8/16/11 for the second treatment Cardinal Health realized that they had provided the entire dose instead of three separate doses of 10.5 milliCuries. Cardinal Health notified Christiana Care of the error.

The treating physician and patient have been notified. No adverse health effects are expected.

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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Agreement State Event Number: 47159
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: SCRUBGRASS GENERATING PLANT
Region: 1
City: KENNERDELL State: PA
County:
License #: PA-1047
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/16/2011
Notification Time: 15:01 [ET]
Event Date: 08/16/2011
Event Time: 13:17 [EDT]
Last Update Date: 08/16/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES TRAPP (R1DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received via fax:

The state reported that their licensee has a gauge with a shutter is in the stuck position. The device contains 300 mCi of Cs-137. The device is secured and no one was exposed during this event. The licensee has contacted the vendor for repairs and will notify the department (Pennsylvania Department of Radiation Protection) when repairs have been made. The department (Pennsylvania Department of Radiation Protection) plans to do a reactive inspection."

PA Report #: PA110021

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Agreement State Event Number: 47163
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: ZILKHA BIOMASS CROCKETT ENERGY LLC
Region: 4
City: HOUSTON State: TX
County:
License #: 06381
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: PETE SNYDER
Notification Date: 08/17/2011
Notification Time: 16:50 [ET]
Event Date: 08/16/2011
Event Time: [CDT]
Last Update Date: 08/17/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
BRUCE WATSON (FSME)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER IDENTIFIED FOLLOWING MAINTENANCE

The following was received via email:

"On August 17, 2011, the Agency [Texas Department of Health] was notified that they were unable to open the shutter on a Ronan Engineering model GS 400 nuclear gauge. The gauge contains 20 milliCuries of cesium 137.

"The gauge had been taken out of service by the licensee to conduct maintenance in the area around the gauge. Once the work was completed, they were unable to get the gauge shutter to open. The licensee has taken the gauge out of service until it can be replaced.

"The gauge does not present an exposure hazard to anyone. The manufacturer has been contacted and is making arrangements to replace the gauge. The gauge was installed in 2010. The Radiation Safety Officer stated that the gauge has been cycled several times since it was installed. The licensee was not able to determine the cause for the failure. Additional information will be provided as it is received."

Texas Incident No. I-8878

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Power Reactor Event Number: 47169
Facility: SEQUOYAH
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MARLIN QUARBERG
HQ OPS Officer: VINCE KLCO
Notification Date: 08/19/2011
Notification Time: 01:10 [ET]
Event Date: 08/18/2011
Event Time: 22:50 [EDT]
Last Update Date: 08/19/2011
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):
SCOTT SHAEFFER (R2DO)

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

Event Text

AUTOMATIC REACTOR TRIP DUE TO REACTOR COOLANT PUMP BUS UNDERVOLTAGE

"At 2250 EDT on 8/18/2011, Unit 1 Reactor/Turbine automatically tripped on RCP [Reactor Coolant Pump] Busses UV [Under-Voltage] trip.

"Following the reactor trip, all safety-related equipment operated as designed. Auxiliary Feedwater automatically actuated as expected from the Feedwater Isolation Signal. No primary PORVs and/or Safety Valves opened during or after this trip.

"Unit 1 is currently being maintained in Mode 3 at NOT/NOP, approximately 548 F [degrees] and 2233 psig, with Auxiliary Feedwater supplying the Steam Generators.

"At the time of the trip, a 50G (instantaneous overcurrent ground) relay flag was found dropped on the '1A' 6.9 KV unit board. Subsequently, the '1A' 6.9 KV start bus was found to have transferred to its alternate supply, 'B' CSST [Common Station Service Transformer]. 1A condenser circulating water pump motor trip out was also received in the MCR [Main Control Room].

"The method of decay heat removal is via steam dumps to the condenser with MSIVs open. The current temperature and pressure is stable. There is no indications of any primary/secondary leakage. All control rods inserted. The electrical alignment is normal with the exception of the above mentioned items, supplied from off-site power. There is no impact to Unit 2. Unit 2 is operating at 100% power/ Mode 1."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47170
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: CHUCK ENGLE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2011
Notification Time: 12:32 [ET]
Event Date: 08/19/2011
Event Time: 10:30 [EDT]
Last Update Date: 08/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
JAMES TRAPP (R1DO)

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

INADVERTENT SOUNDING OF EMERGENCY PREPAREDNESS ZONE SIREN

"Limerick Generating Station Site EP [Emergency Preparedness] Manager was informed by Chester County 911 Dispatch Center that Limerick Emergency Preparedness Zone (EPZ) Siren #132, located at Pothouse Road West of Ridgeview Road in Chester County, was sounding. Notification occurred at 1030 hrs. [EDT] 8/19/11.

"The siren maintenance contractor was contacted, and the sounding was terminated at 1120 hrs. 8/19/11.

"No actual plant emergency exists. The siren activation was caused by equipment malfunction.

"[The] remaining 164 of 165 Limerick EPZ Sirens remain functional, no other reportability threshold(s) have been met or exceeded.

"An 'Event of Potential Public Interest' will be issued to the state and local agencies."

The maintenance contractor is currently troubleshooting the cause. The licensee will be notifying the NRC Resident Inspector.

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Power Reactor Event Number: 47171
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: TYLER HALYE
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2011
Notification Time: 13:43 [ET]
Event Date: 06/21/2011
Event Time: 13:08 [EDT]
Last Update Date: 08/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.73(a)(1) - INVALID SPECIF SYSTEM ACTUATION
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

Event Text

60-DAY OPTIONAL TELEPHONIC NOTIFICATION OF INVALID SPECIFIED SYSTEM ACTUATION

"Invalid Actuation of Turbine Driven Auxiliary Feedwater (TDAFW) pump.

"This telephone notification is being made under reporting requirements specified by 10 CFR 50.73(a)(2)(iv)(A) and 10 CFR 50.73(a)(1).

"On 6/21/11 at 1308 EDT, during maintenance activities for replacement of relay UVTXSB/1732, associated with 6.9kv Emergency Bus 1B-SB undervoltage trip circuitry, an automatic start of the Turbine Driven Auxiliary Feedwater (TDAFW) pump occurred while using a new procedure, CM-E0032. At the time of the event, all steam generator levels were normal. The TDAFW pump was secured by Operations on 6/21/11 at 1311 EDT.

"No actual condition existed that would require an automatic start of the TDAFW pump and therefore this event has been classified as an invalid actuation.

"The start of the TDAFW is considered a complete train actuation. The system started and functioned successfully."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 47172
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARTIN LICHTNER
HQ OPS Officer: PETE SNYDER
Notification Date: 08/19/2011
Notification Time: 14:06 [ET]
Event Date: 08/19/2011
Event Time: 10:46 [EDT]
Last Update Date: 08/19/2011
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):
JAMES TRAPP (R1DO)

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

Event Text

REACTOR SCRAM DURING QUARTERLY SURVEILLANCE TEST

"At 1046 hours on August 19, 2011, Susquehanna Steam Electric Station Unit 2 reactor scrammed while [operators were] performing a quarterly functional test of reactor water high level trip channels for feedwater / main turbine. The main turbine tripped when a single channel high reactor water level signal was inserted, which was unexpected. Actual water level was within the normal band when the main turbine tripped. The main turbine trip resulted in a reactor scram. Reactor recirculation pump trips as designed and all control rods inserted. Reactor water level lowered to +2 inches causing Level 3 (+ 13 inches) isolations. Reactor water level was restored to the normal operating band using the feedwater system. Six main steam relief valves opened for a short duration, as expected, due to the turbine trip transient. Subsequently, reactor pressure was controlled via turbine bypass valve operation. All safety systems operated as expected. No ECCS or RCIC initiations occurred or were required.

"The reactor recirculation pumps were subsequently restarted to re-establish forced core circulation.

"The reactor is currently stable in Mode 3. An investigation into the cause of the scram is underway.

"Unit 1 was unaffected and continued power operation.

"The NRC Resident Inspector was notified. A press release will occur."

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Fuel Cycle Facility Event Number: 47176
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: CALVIN PITTMAN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/19/2011
Notification Time: 16:26 [ET]
Event Date: 08/19/2011
Event Time: 08:15 [CDT]
Last Update Date: 08/19/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
RESPONSE-BULLETIN
Person (Organization):
SCOTT SHAEFFER (R2DO)
KING STABLEIN (NMSS)
BILLY DICKSON (R3DO)

Event Text

24-HR LOSS OF CRITICALITY CONTROL REPORT REQUIRED UNDER BULLETIN 91-01, SUPPLEMENT 1

"At 0815 CDT on 08-19-11, a Chemical Operations First Line Manager discovered that during disassembly of a single Seal Exhaust/Wet Air (SX/WA) pump, pump housing subcomponents (i.e. two piston slides and a cam) were placed within 2 feet of the internal oil separators. Nuclear Criticality Safety Approval (NCSA) GEN-011 requires a minimum 2-foot edge-to-edge spacing between pump housing subcomponents and internal oil separators. The purpose of this control is to ensure interaction between grossly contaminated fissile items is minimized during movement and storage. The Plant Shift Superintendent and the NCS group were notified and access to the area was controlled.

"Since one leg of double contingency was lost, this is being reported to the NRC as a 24-hour Event Report in accordance with NRC BL 91-01, Supplement 1.

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

"PGDP Problem Report No. ATRC-11-2161

"PGDP Event Report No. PAD-2011-13

"POTENTIAL CRITICALITY PATHWAYS INVOLVED: In order for a criticality to be possible, the components would have to be grossly contaminated and brought together in a geometry capable of supporting a criticality and an additional spacing violation would have to occur before a criticality is possible.

"CONTROLLED PARAMETERS: Double contingency is maintained by implementing controls on geometry and interaction.

"ESTIMATED AMOUNT, ENRICHMENT, FORM OF LICENSED MATERIAL : Uranium contaminated oil. Product withdrawal assay at the time of the event was less than 4.95 wt% U235. The pump components were not grossly contaminated.

"NUCLEAR CRITICALITY SAFETY CONTROL(S) OR CONTROL SYSTEM(S) AND DESCRIPTION OF THE FAILURES OR DEFICIENCIES: The first leg of double contingency relies on the geometry of the seal exhaust/wet air pump components. The pump components are controlled as safety related items. This control was not violated. Therefore, this leg of double contingency was maintained. The second leg of double contingency relies on minimizing interaction between internal oil separators and pump housing subcomponents. Interaction is controlled by maintaining a minimum 2-foot edge-to-edge spacing between pump internal oil separators and pump housing subcomponents. The pump housing subcomponents were placed within 2 feet of the internal oil separators in violation of this control. The interaction parameter was not maintained; therefore this leg of double contingency was not maintained. Double contingency was not maintained because the interaction parameter was not maintained.

"CORRECTIVE ACTIONS TO RESTORE SAFETY SYSTEMS AND WHEN EACH WAS IMPLEMENTED:
1. Control Access to the area. This was completed at 0845 CDT on 08/19/11.
2. Move one item at a time such that the spacing between the pump housing subcomponents and the internal oil separators is always increasing until a minimum 2-foot edge-to-edge spacing has been established. This was completed at 1445 CDT on 08/19/11.
3. Upon establishing the proper spacing between the pump housing subcomponents and the internal oil separators, the exclusion zone may be removed. This was accomplished at 1450 CDT on 08/19/11."

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Power Reactor Event Number: 47177
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [ ] [3] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: JAVIER HERRERA
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/19/2011
Notification Time: 23:54 [ET]
Event Date: 08/19/2011
Event Time: 18:05 [EDT]
Last Update Date: 08/20/2011
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
JAMES TRAPP (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N Y 100 Power Operation 75 Power Operation

Event Text

PARTIAL LOSS OF OFFSITE POWER RESULTING IN EDG AUTOSTART

"At 1805 Indian Point Unit 3 experienced a loss of normal 138 KV Offsite Power (LOOP) during a thunderstorm in the area. The Station Auxiliary Transformer (SAT) protection circuitry actuated and de-energized 6.9 KV buses 5 and 6. Thirty two and 33 Emergency Diesel Generators (EDGs) auto-started and loaded onto Safeguards buses 5A and 6A per plant design. The corresponding blackout logic resulted in an auto start of 32 and 33 Auxiliary Feed Water pumps (AFW). The plant remained in Mode 1; however, due to the loss of two 6.9 KV buses, three Circulating Water pumps (CW) tripped as designed, which caused main condenser backpressure to rise (i.e., vacuum degraded). As a result of rising condenser backpressure, a manual turbine load reduction to 75% power was performed. The reactor remains stable at 75% power and buses 5 and 6 have been manually re-energized from the alternate 13.8 KV offsite power source and the Emergency Diesel Generators have been unloaded, shutdown, and realigned for auto start capability.

"The only unusual system response was 32 Component Cooling Water (CCW) pump did not auto-start on a low pressure signal when the remaining pumps were stripped and re-Ioaded by the EDG sequencing logic due to a problem with the closing spring on the supply breaker. CCW system pressure was observed to be at normal levels when 31 and 33 CCW pumps were loaded on the EDGs. 32 CCW pump remains inoperable due to the breaker issue.

"There was no impact to the operation of Unit 2 during this event."

The licensee has notified the NRC Resident Inspector and the New York State Public Service Commission.

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