United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for March 26, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
03/23/2012 - 03/26/2012

** EVENT NUMBERS **


47756 47765 47766 47767 47769

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Non-Agreement State Event Number: 47756
Rep Org: MIDDLESEX CARDIOLOGY ASSOCIATES
Licensee: MIDDLESEX CARDIOLOGY ASSOCIATES
Region: 1
City: MIDDLETOWN State: CT
County:
License #: 062355901
Agreement: N
Docket:
NRC Notified By: JOSEPH CORNING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/20/2012
Notification Time: 13:25 [ET]
Event Date: 03/20/2012
Event Time: 12:30 [EDT]
Last Update Date: 03/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
WAYNE SCHMIDT (R1DO)

Event Text

INCORRECT PATIENT ADMINISTERED NUCLEAR STRESS TEST

"This will serve as the incident report on a patient who inadvertently received an injection of technetium 99m in the Middletown office of Middlesex Cardiology Associates. [The gentleman] is a 68-year-old patient. He has underlying dementia and, at times, poor understanding of his medical care. He arrived at the office over 30 minutes late for his appointment. He identified himself to the front office staff [by his first name]. Because of HlPPA laws, the front office staff did not announce his full name. It turns out that a separate patient, [with the same first name] was scheduled for a 12:30 PM nuclear stress test. [The patient] was brought to the nuclear cardiology imaging department which is separate from the usual patient waiting room. He was told that he was going to have a pharmacologic stress test performed. Before the medical assistant could ask his date of birth, the patient indicated to the nuclear staff that he had had coffee earlier in the day which raised some confusion as to whether he could undergo pharmacologic stress testing. [The patient] never indicated that he was simply there for an office visit. He was subsequently told that he could only have resting imaging performed and would have to return on a separate day for the pharmacologic stress test. He agreed. He had undergone previous nuclear testing and therefore did not protest having an injection of technetium performed. He subsequently received 32.8 mCi of technetium 99 sestamibi. At that point, the correct nuclear stress test patient, checked in with the front office staff. Immediately, it became evident that there were 2 gentleman [with the same first name] scheduled for separate visits on 3/20/12. License photo identification was then performed. It was then discovered that [the first patient] had inadvertently received the technetium injection inappropriately. Given the fact that this dose of technetium would only produce a total body dose of 0.55 rads or approximately 5.3 mGy, there was not felt to be any concern for long-term medical sequelae.

"The patient's physician had a discussion with the patient and subsequently called his daughter to discuss the incident. A detailed letter was also sent to the patient's primary care physician.

"Based on NRC regulations, I contacted the [NRC] Operations Center at 1:25 PM on 3/20/12. I spoke to [the Headquarters Operations Officer] to explain the situation. This afternoon, we had a meeting with all front office staff and nuclear staff to review the importance of patient identification so that this type of incident will never occur again. Patients for nuclear testing will be identified by first and last names as well as birthdates to eliminate confusion."

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: 47765
Facility: VOGTLE
Region: 2 State: GA
Unit: [3] [4] [ ]
RX Type: [3] W-AP1000,[4] W-AP1000
NRC Notified By: HOWARD MAHAN
HQ OPS Officer: STEVE SANDIN
Notification Date: 03/23/2012
Notification Time: 14:33 [ET]
Event Date: 03/22/2012
Event Time: 21:01 [EDT]
Last Update Date: 03/23/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
ROBERT HAAG (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
3 N N 0 Under Construction 0 Under Construction
4 N N 0 Under Construction 0 Under Construction

Event Text

FITNESS FOR DUTY [FFD] REPORT INVOLVING PROGRAMMATIC VULNERABILITY

"On March 9, 2012, Shaw's Vogtle 3&4 Construction Contractor FFD program manager notified SNC [Southern Nuclear Operating Company] FFD program manager of his discovery of anomalies in their random pool while preparing to perform the weekly random pool generation. At that time, approximately 20 people were identified as not being in the pool that had active badges. Corrective actions were implemented to update the pool and provide additional verification of any changes made to the pool. Subsequently discussions with licensing resulted in the conclusion that there was not an indication that there was a programmatic issue and thus was reportable under a 30 day report to the NRC. The NRC was informed of this decision and has been at Vogtle collecting data regarding this event.

"Since that time, Shaw has been checking past months to determine the extent of condition. On March 22, at 21:01, Shaw notified SNC that the October - December results of personnel who had active badges but was not in the pool was significantly higher than the January through March results, developed earlier. On the basis of this information, SNC has determined that this now rises to the level of a programmatic vulnerability and is subject to a 24-hour report to the NRC.

"SNC is providing this notification under the provisions of 10 CFR 26.719(b)(4) as a discovered vulnerability of the FFD program."

The licensee informed the NRC Resident Inspectors.

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Power Reactor Event Number: 47766
Facility: SALEM
Region: 1 State: NJ
Unit: [ ] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: JOHN OSBORNE
HQ OPS Officer: PETE SNYDER
Notification Date: 03/23/2012
Notification Time: 17:00 [ET]
Event Date: 03/23/2012
Event Time: 14:28 [EDT]
Last Update Date: 03/23/2012
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):
WAYNE SCHMIDT (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 Standby

Event Text

TURBINE TRIP FOLLOWED BY AUTOMATIC REACTOR TRIP

"Salem Unit 2 has experienced an automatic reactor trip at 1428 hours on 3/23/12.

"Salem Unit 2 tripped due to a turbine trip above [permissive] P-9. All shutdown and control rods fully inserted on the reactor trip.

"At the time of the trip 22 station power transformer [SPT], the 2F and 2G 4KV group buses were not energized causing a loss of 23 and 24 reactor coolant pumps. The auxiliary feedwater (AFW) system auto-started to provide feed to the steam generators.

"The crew entered EOP-TRIP-1, then transitioned to the EOP-TRIP-2 and stabilized the plant. Salem Unit 2 is currently in Mode 3 at normal operating temperature and pressure with 21 and 22 reactor coolant pumps in service.

"There are no shutdown technical specifications in effect. All ECCS and ESF systems are available. Decay heat removal is being provided by 21 and 22 AFW pumps and the main steam dump system. The plant is aligned with a normal electrical line-up from offsite power sources with the exception of 22 SPT. Restoration of the 22 SPT and 2F and 2G 4KV group buses is in progress.

"There were no personnel injuries associated with this event.

"This event is reportable per 10 CFR 50.72 (b)(3)(iv)(A) due to the auto-start of the auxiliary feed water pumps."

The licensee notified the NRC Resident Inspector. The licensee will notify Lower Alloways Creek Township and the States of New Jersey and Delaware. The licensee anticipates making a press release.

* * * UPDATE FROM WILLIAM MUFFLEY TO PETE SNYDER AT 2127 EDT ON 3/23/12 * * *

"During the post trip review ... two additional AFW pump start signals were identified. At 1429 hrs. EDT with RCPs 23 and 24 tripped the 21 and 22 steam generators (SG) dipped below the lo-lo level setpoints and caused an AFW actuation to occur. At 1457 hrs. EDT 23 turbine driven AFW pump was stopped in accordance with operating procedures. At 1509 hrs. EDT the 21 SG cleared the low level setpoint and at 1513 hrs. EDT the 22 SG cleared the low level setpoint. At 1523 hrs. EDT the 22 SG dipped below the lo-lo level setpoint and caused an AFW actuation to occur. The two motor drive AFW pumps continued to run throughout this event.

"The licensee notified the NRC Resident Inspector and will notify Lower Alloways Creek Township and the States of New Jersey and Delaware."

Notified R1DO (Schmidt).

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Power Reactor Event Number: 47767
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: PAGE KEMP
HQ OPS Officer: VINCE KLCO
Notification Date: 03/25/2012
Notification Time: 01:44 [ET]
Event Date: 03/24/2012
Event Time: 18:55 [EDT]
Last Update Date: 03/25/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
ROBERT HAAG (R2DO)

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

Event Text

DEGRADATION OF STEAM GENERATOR NOZZLE WELD AREAS

"On March 24, 2012, at 1855 [EDT] during the performance of work activities to support Alloy 600 dissimilar metal weld overlay work on the 'B' Reactor Coolant loop hot leg to the 'B' Steam Generator nozzle weld, two through-wall defects were identified. The workers noted a small amount of water seeping from the indications in the nozzle weld area. The indications are in the area of excavation that was being performed for the weld overlay project. Approximately 1 [inch] of weld material had been removed prior to the seepage being identified.

"Entered Technical Requirement 3.4 .6, 'ASME Code Class 1, 2 and 3 Components' and immediately initiated actions to isolate the 'B' Reactor Coolant loop. The 'B' Reactor Coolant loop stop valves were closed at 2312 hours on March 24, 2012, which isolated the defects from the reactor coolant system . An engineering evaluation of the defects will be performed and corrective actions implemented.

"This event is reportable in accordance to 10CFR50.72(b)(3)(ii)(A) for 'any event or condition that results in the condition of the nuclear power plant, including its principle safety barriers, being seriously degraded'."

The licensee notified the NRC Resident Inspector and will notify Louisa County.

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Power Reactor Event Number: 47769
Facility: NORTH ANNA
Region: 2 State: VA
Unit: [1] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: TED WEBNER
HQ OPS Officer: VINCE KLCO
Notification Date: 03/25/2012
Notification Time: 23:58 [ET]
Event Date: 03/25/2012
Event Time: 23:36 [EDT]
Last Update Date: 03/26/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
VICTOR MCCREE (R2RA)
ERIC LEEDS (NRR)
ROBERT HAAG (R2DO)
JEFF GRANT (IRD)
FREDERICK BROWN (NRR)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N N 0 Refueling 0 Refueling
2 N Y 100 Power Operation 100 Power Operation

Event Text

UNUSUAL EVENT DECLARED DUE TO SEISMIC ACTIVITY

On March 25, 2012 at 2336 EDT, an Unusual Event was declared due to an earthquake felt on site. The site entered EAL HU1.1. No plant systems were affected. The National Earthquake Information Center reported a magnitude 3.1 seismic event 6 miles south-south west of Mineral, Virginia. A plant inspection is on-going to determine any plant issues related to the seismic event. Unit 1 is in a refueling outage and containment integrity was maintained. Unit 2 continues in full power operation.

The licensee notified the NRC Resident Inspector, State and local agencies.

Notified DHS SWO, FEMA, NICC and Nuclear SSA via email.

* * * UPDATE FROM TED WEBNER TO VINCE KLCO ON 3/26/2012 AT 0417 EDT * * *

On March 26, 2012 at 0410 EDT, the Unusual Event was terminated. The basis for the termination was that all equipment walkdowns are complete with no damage discovered.

The licensee will notify the NRC Resident Inspector.

Notified the R2DO (Haag), NRR EO (Brown), IRD (Grant), DHS SWO, FEMA, NICC and the Nuclear SSA via email.

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