United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for March 19, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/16/2012 - 03/19/2012

** EVENT NUMBERS **


47737 47738 47743 47744 47748 47749 47752

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Agreement State Event Number: 47737
Rep Org: NJ RAD PROT AND REL PREVENTION PGM
Licensee: CLARA MAASS MEDICAL CENTER
Region: 1
City: BELLEVILLE State: NJ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RICHARD PEROS
HQ OPS Officer: PETE SNYDER
Notification Date: 03/13/2012
Notification Time: 11:22 [ET]
Event Date: 03/12/2012
Event Time: [EDT]
Last Update Date: 03/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
PAUL KROHN (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - ABORTED FRACTIONAL DOSE TREATMENT

The following information was received from the State of New Jersey:

"A patient was treated with a Nucletron microSelectron 106.990(v3) HDR unit on March 12, 2012. The prescription dose was 600 cGy per fraction for 5 fractions. The fractional treatment planned was for a total of 14 dwell positions in two different catheters: six dwell positions in the ring to be treated on HDR Channel 1 and eight dwell positions in the tandem to be treated on HDR Channel 3. After all appropriate QA, the patient treatment was started with Channel 1 being the first set of dwell positions treated. At the completion of the Channel 1 treatment, the HDR unit gave an error stating that there was a 'Possible incomplete source retraction in Channel 2.' Even though all radiation indicators did not detect the presence of radiation, and even though the licensee was not using Channel 2, immediate emergency procedures were implemented. The emergency stop was activated and the room was entered with a survey meter to verify that there was no elevated radiation present. All indications were that the source was retracted properly and that there was no danger to the patient or the staff.

"The error displayed on the treatment screen indicated that it was possible that dust was on the optocoupler, thus causing the fault. However, the error could not be cleared by using the reset button. Nucletron was immediately contacted. Nucletron support personnel attempted to walk the licensee through some steps that may have cleared the error, but they were unsuccessful. Therefore, the remaining part of the patient's treatment was aborted. Nucletron scheduled one of their service engineers to respond to the licensee's facility to repair the unit.

"The authorized user informed the patient that the complete treatment was not delivered due to the machine malfunction and that the authorized user would determine what action to take on the future fractions. The patient and the treatment room were surveyed prior to release. No elevated readings were observed. The patient received 120 cGy (versus the prescribed dose of 600 cGy). The deviation from the written directive was documented in the patient's chart."

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: 47738
Rep Org: COLORADO DEPT OF HEALTH
Licensee: HIGH MOUNTAIN INSPECTION
Region: 4
City: GREELEY State: CO
County:
License #: 1042-01
Agreement: Y
Docket:
NRC Notified By: ED STROUD
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/13/2012
Notification Time: 17:39 [ET]
Event Date: 03/13/2012
Event Time: [MDT]
Last Update Date: 03/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHUCK CAIN (R4DO)
JAMES DANNA (FSME)
DENNIS ALLSTON (ILTA)

This material event contains a "Category 2" level of radioactive material.

Event Text

AGREEMENT STATE REPORT - RADIOGRAPHY CAMERA WAS LOST AND RECOVERED

A radiographer working for High Mountain Inspection was conducting radiography on a pipeline near De Beque, CO. The radiographer failed to secure the camera in his pickup truck when he drove off to the next location. Arriving at his destination the radiographer realized his camera was missing and retraced his steps. The radiography camera with a 26 Curie, Ir-192 source was not located.

At 1826 EDT the State of Colorado called and said a member of the public had found the missing camera and called the licensee. The licensee is now in possession of the radiography camera and the source has not been tampered with.

The camera is a SPEC, s/n 150. The source s/n is SJ0702.

THIS MATERIAL EVENT CONTAINS A "CATEGORY 2" LEVEL OF RADIOACTIVE MATERIAL

Category 2 sources, if not safely managed or securely protected, could cause permanent injury to a person who handled them, or were otherwise in contact with them, for a short time (minutes to hours). It could possibly be fatal to be close to this amount of unshielded radioactive material for a period of hours to days. These sources are typically used in practices such as industrial gamma radiography, high dose rate brachytherapy and medium dose rate brachytherapy. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 47743
Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [2] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: RYAN HAMILTON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 03/14/2012
Notification Time: 17:32 [ET]
Event Date: 03/14/2012
Event Time: 13:05 [EDT]
Last Update Date: 03/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
PAUL KROHN (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

LOSS OF THE TONE ALERT RADIO SYSTEM

"On Monday, March 12, 2012, at 1435 EDT, Oswego County Warning Point notified Nine Mile Point, and NYS [New York State] Warning Point, via the land line, of a loss of the Tone Alert System for greater than one hour from the National Weather Service as of 1305 hrs. Site Emergency Procedures define a loss of Tone Alert System for greater than one hour, as a significant loss of Emergency Communications (EPIP-EPP-30).

"This impacts the ability to readily notify a portion of the Emergency Planning Zone (EPZ) population for the NMP [Nine Mile Point] and JAF [James A. Fitzpatrick] Nuclear Power Plants. This failure meets NRC 8-Hour reporting criteria 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 System constitutes a significant loss of Emergency Off-Site 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 licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM NATHAN LILIENTHAL TO VINCE KLCO AT 1050 EDT ON 3/15/2012 * * *

"The tone alert system was restored Thursday, March 15, 2012 at 0933 EDT."

The licensee notified the NRC Resident Inspector.

Notified the R1DO (Krohn).

* * * UPDATE FROM JOHN APRIL TO JOHN SHOEMAKER AT 1421 EDT ON 03/16/2012 * * *

"Correction to original notification: In the description above, the date of event was incorrectly identified as Monday, March 12, 2012, the date should have been Wednesday, March 14, 2012."

Notified the R1DO (Krohn).

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Power Reactor Event Number: 47744
Facility: SAN ONOFRE
Region: 4 State: CA
Unit: [ ] [ ] [3]
RX Type: [1] W-3-LP,[2] CE,[3] CE
NRC Notified By: RYAN TREADWAY
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/14/2012
Notification Time: 18:20 [ET]
Event Date: 03/14/2012
Event Time: 11:20 [PDT]
Last Update Date: 03/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
CHUCK CAIN (R4DO)

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

UNIT 3 STEAM GENERATOR TUBES FAILED IN-SITU PRESSURE TESTING

"On January 31, 2012, Unit 3 was shut down due to detection of a tube leak in one Steam Generator (SG). The shutdown was previously reported on Event Notification # 47628. Southern California Edison (SCE) has been performing in-situ pressure testing with non-radioactive water on tubes with significant wear indications. On March 14, 2012, at approximately 1120 PDT, Unit 3 Steam Generator (SG) E088 Tube R106 C78 did not meet the target performance criteria because leakage exceeded 0.5 gallons per minute at the maximum pressure achieved during the test (2,884 psig). This was the leaking tube that resulted in the Unit 3 shutdown.

"Subsequently, two additional tubes in Unit 3 SG E088 did not meet the target performance criteria as follows: at 1249 PDT, Tube R102 C78 exceeded 0.5 gallons per minute at 3,268 psig and at 1425 PDT, Tube R104 C78 exceeded 0.5 gallons per minute at 3,180 psig. These occurrences are reportable as an 8-hour notification to the NRC in accordance with 10 CFR 50.72(b)(3)(ii)(A). Testing and inspection of Unit 3 steam generator tubes is ongoing to determine the extent and cause of the observed wear. A follow-up notification will be made for additional in-situ pressure test failures. The extent and cause of the condition will be addressed in the follow-up licensee event report that will be submitted in accordance with 10 CFR 50.73(a)(2)(ii)(A). Defective tubes will be removed from service as required prior to Unit 3 plant startup.

"Unit 2 has been shut down since January 9, 2012 for a scheduled refueling outage. SCE previously performed in-situ pressure testing of the tube with the most wear in Unit 2. Results from this test demonstrated that the tube met the target performance criteria.

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


* * * UPDATE FROM LEE KELLY TO DONALD NORWOOD AT 2108 EDT ON 3/15/2012 * * *

"In-situ pressure testing on Unit 3 steam generator tubes was started on March 14, 2012 and is ongoing. On March 15, 2012, four additional tubes in Unit 3 SG E088 did not meet the target performance criteria of three-times normal pressure conditions as follows: (1) At 1109 PDT, Tube R100 C80 failed at 4,739 psig; (2) at 1437 PDT, Tube R107 C77 failed at 5,160 psig; (3) at 1604 PDT, Tube R101 C81 failed at 4,889 psig; and (4) at 1734 PDT, Tube R98 C80 failed at 4,886 psig.

"Testing and inspection of Unit 3 steam generator tubes is ongoing to determine the extent and cause of the observed wear. Follow-up notifications will be made for any additional in-situ pressure test failures."

The licensee notified the NRC Resident Inspector. Notified R4DO (Cain).

* * * UPDATE FROM LEE KELLY TO JOHN SHOEMAKER AT 2115 EDT ON 3/16/12 * * *

"In-situ pressure testing on Unit 3 steam generator tubes was started on March 14, 2012 and is ongoing. On March 16, 2012, one additional tube in Unit 3 SG E088 did not meet the target performance criteria of three-times normal pressure conditions as follows: at 1216 PDT, Tube R99 C81 failed at 5,026 psig.

"Testing and inspection of Unit 3 steam generator tubes is ongoing to determine the extent and cause of the observed wear. Follow-up notifications will be made for any additional in-situ pressure test failures."

The licensee notified the NRC Resident Inspector. Notified R4DO (Cain).

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Power Reactor Event Number: 47748
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: WARREN WONKA
HQ OPS Officer: VINCE KLCO
Notification Date: 03/16/2012
Notification Time: 10:56 [ET]
Event Date: 03/16/2012
Event Time: 04:00 [EDT]
Last Update Date: 03/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
EUGENE GUTHRIE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N N 0 Hot Shutdown 0 Hot Shutdown

Event Text

REFUELING WATER STORAGE TANK CONNECTED TO AN UNQUALIFIED SYSTEM

"The Refueling Water Storage Tank (RWST) was placed on purification in accordance with [site procedure] OP-913, Refueling Water Purification Pump Operation, as directed from OP-301-1, Chemical and Volume Control System (Infrequent Operation), at 0400 [EDT] on 3/16/2012 to support make up of level to the RWST. This condition, connection of the purification loop, is not currently allowed based on unresolved seismic concerns with purification piping to the RWST. This was later discovered during a log review at 0545, and operators were immediately directed to remove the RWST from purification. ITS 3.5.4 was applied from 0400 based on when it was determined that this condition had been entered. ITS 3.5.4 was exited at 0622 when the RWST was removed from purification.

"This is being reported pursuant to 50.72(b)(3)(v), Event or Condition That Could Have Prevented Fulfillment of a Safety Function."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47749
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: MICAH BENNINGFIELD
HQ OPS Officer: DONALD NORWOOD
Notification Date: 03/16/2012
Notification Time: 14:29 [ET]
Event Date: 03/11/2012
Event Time: 14:30 [CDT]
Last Update Date: 03/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHUCK CAIN (R4DO)

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

TECHNICAL SUPPORT CENTER BACKUP DIESEL GENERATOR DECLARED NON-FUNCTIONAL

"On March 11, 2012, a maintenance test of the Technical Support Center (TSC) diesel generator was performed. This diesel generator supplies backup A/C power to the TSC in the event of a loss of normal power. During this test, with the diesel generator supplying power to the TSC, two unexpected momentary losses of normal lighting to the TSC were observed. Following this event, the TSC diesel generator was declared non-functional.

"High-priority actions to troubleshoot and repair the TSC diesel generator were taken following this event. However, as of 1200 CDT on March 16, 2012, troubleshooting activities are still ongoing, and the cause of the event has not yet been identified.

"Normal power to the TSC has been available throughout this event, and the TSC is considered functional. However, due to the duration of the TSC diesel generator non-functionality, Callaway Plant is reporting this condition in accordance with 10 CFR 50.72(b)(3)(xiii) for a loss of emergency assessment capability.

"Please note that, in the event of a complete loss of power to the TSC concurrent with a plant emergency, the designated backup facilities will be used in accordance with the Callaway Plant emergency preparedness program procedures.

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 47752
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: FRED POLLAK
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/19/2012
Notification Time: 02:24 [ET]
Event Date: 03/18/2012
Event Time: 23:36 [EDT]
Last Update Date: 03/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
EUGENE GUTHRIE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 1 Startup 0 Hot Standby

Event Text

MANUAL REACTOR TRIP DUE TO CONTROL ELEMENT ASSEMBLY ANOMALOUS BEHAVIOR

"At 2336 EDT, during performance at Low Power Physics Testing, Unit 1 was manually tripped while the reactor was critical at less than 1% power due to Control Element Assembly (CEA) Regulating Group #3 exhibiting anomalous behavior (continued to insert with no operator action). The trip was uncomplicated and all CEAs fully inserted when the reactor was tripped. No automatic safety system actuations were required and none occurred. The cause for the abnormal CEA performance is under investigation.

"The plant is stable in Mode 3 at normal operating temperature and pressure. RCS Heat Removal is being maintained with Auxiliary Feedwater and Atmospheric Dump Valves. The offsite power grid is available and stable.

"This non-emergency notification is being made pursuant to 10 CFR 50.72(b)(2)(iv)(B) due to manual RPS actuation with the reactor critical"

The NRC Resident Inspector has been informed.

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