United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 5, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/04/2012 - 04/05/2012

** EVENT NUMBERS **


47790 47792 47803 47805 47806 47807

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Agreement State Event Number: 47790
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: LARKIN COMMUNITY HOSPITAL
Region: 1
City: SOUTH MIAMI State: FL
County:
License #: 2825-2
Agreement: Y
Docket:
NRC Notified By: CHARLES ADAMS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 03/30/2012
Notification Time: 08:07 [ET]
Event Date: 03/08/2012
Event Time: [EDT]
Last Update Date: 03/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - GAMMA KNIFE MEDICAL OVEREXPOSURE

The following information was received from the State of Florida via email:

"Licensee reported a possible medical event on 8 March which was confirmed in a written report received on 22 March. Patient was being treated by Gamma Knife with 8 shots at four sites when the fifth shot was interrupted for a bathroom break. While in the bathroom the patient fell and dislodged the stereotactic frame. The frame was reapplied and treatment plan recalculated. However, the computer did not start the treatment at the correct site resulting in an increase in dose of 22.2% at site 2, 14.8% at site 3 & 15, and 7% at site 4. The doses are well within clinical practice. A conservative dose prescription had been elevated to a moderate prescription. The referring physician and patient have been notified. No medical consequences are expected. The cause is human error. Any further investigation referred to Licensing and Materials. No further action will be taken on this incident by this office."

Device: Leksell Perfexion
Serial Number: 6130

Florida Incident: FL-12-034

"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: 47792
Rep Org: ARIZONA RADIATION REGULATORY AGENCY
Licensee: UNKNOWN
Region: 4
City: TEMPE State: AZ
County:
License #:
Agreement: Y
Docket:
NRC Notified By: AUBREY GODWIN
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/30/2012
Notification Time: 16:36 [ET]
Event Date: 03/28/2012
Event Time: 13:35 [MST]
Last Update Date: 03/30/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
THOMAS FARNHOLTZ (R4DO)
CHRISTEPHER MCKENNEY (FSME)

Event Text

AGREEMENT STATE REPORT - A MOISTURE DENSITY GAUGE WAS FOUND IN BUILDING

The following information was received from the State of Arizona via email:

"At approximately 10:00 AM on March 28, 2012, the Agency [Arizona Radiation Regulatory Agency (ARRA)] was informed that radioactive material had been detected by the Tempe, AZ Fire Department in an old flour mill. The Agency [ARRA] dispatched a response team to the site to locate and confirm information. The response team determined that the isotope involved is Cesium-137 and based on the label information approximately 25 millicuries remain in the device. The device is labeled on the accessible surfaces as a Kay Ray Model 7107 gauge and also as a Model 7519B gauge assembly SN 13454. Based on the site history and the labels, it appears that the device was transferred to Bay State Milling in the 4th quarter of 1980 or the 1st quarter of 1981. The Agency [ARRA] did not issue a specific license for this site. We assume that the device was transferred as a GL (Generally Licensed) device and remained in use into 1998. Only about 10% of the site has been surveyed thus far. The site security is being maintained by the Tempe FD (Fire Department).

"The Agency [ARRA] is now searching historical records for information, including any other devices on site.

"The Agency [ARRA] continues its investigation."

Arizona Report #: 12-008

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Power Reactor Event Number: 47803
Facility: INDIAN POINT
Region: 1 State: NY
Unit: [2] [ ] [ ]
RX Type: [2] W-4-LP,[3] W-4-LP
NRC Notified By: BRIAN VANGOR
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/04/2012
Notification Time: 05:15 [ET]
Event Date: 04/04/2012
Event Time: 05:00 [EDT]
Last Update Date: 04/04/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
JOHN CARUSO (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 48 Power Operation 43 Power Operation

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO INOPERABLE STATIC INVERTER

"Indian Point 2 commenced a Technical Specification required shutdown in accordance with Limiting Condition of Operation 3.8.7, Condition B at 0500 hours on 04/04/2012 due to the inoperability of '24' Static Inverter - a component in the 118VAC Distribution System. Indian Point 2 is required to be in Mode 3 by 0802 hours. Repair of the '24' Static Inverter is in progress.

"The NRC Resident Inspector has been notified."

The licensee also notified the NY State Public Service Commission.


* * * UPDATE FROM P. SCHOAN TO DONALD NORWOOD AT 1053 EDT ON 4/4/2012 * * *

At 0538 hours, the Technical Specification shutdown was stopped following the repair and return to service of the '24' Static Inverter.

The licensee notified the NRC Resident Inspector.

Notified R1DO (Caruso).

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Power Reactor Event Number: 47805
Facility: CATAWBA
Region: 2 State: SC
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DON WISNIEWSKI
HQ OPS Officer: PETE SNYDER
Notification Date: 04/04/2012
Notification Time: 20:25 [ET]
Event Date: 04/04/2012
Event Time: 20:03 [EDT]
Last Update Date: 04/05/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
Person (Organization):
GERALD MCCOY (R2DO)
ROBERT NELSON (NRR)
VICTOR MCCREE (R2)
DAN DORMAN (NRR)
WILLIAM GOTT (IRD)

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
2 N N 0 Cold Shutdown 0 Cold Shutdown

Event Text

NOTICE OF UNUSUAL EVENT DUE TO DUAL UNIT LOSS OF OFFSITE POWER

At 2003 EDT on 4/4/12 Catawba Unit 1 automatically tripped due to a loss of offsite power. The licensee declared a Notice of Unusual Event due to entry into EAL 4.5.U.1, 'AC Electrical Power from All Offsite Sources Has Been Lost for Greater Than 15 Minutes.' Power is still available from onsite sources. All four Emergency Diesel Generators [EDG] started and powered their respective safety buses.

"The EAL poses no threat to the safety of the public."

The Unit 1 control rods fully inserted, there is no known primary to secondary leakage, and the auxiliary feedwater water system automatically started.

The licensee notified the NRC Resident Inspector

Notified: DHS SWO, FEMA, DHS NICC, USDA, HHS, DOE, EPA, and Nuclear SSA via email.


* * * UPDATE AT 0150 EDT ON 04/05/12 FROM DARRYL HELTON TO S. SANDIN * * *

Catawba Nuclear Generating Station exited the Unusual Event at 0137 EDT after restoring offsite power at 0135 EDT to the Unit 1A and Unit 2B essential busses. The EDGs powering these busses have been secured and returned to Standby.

The Unit 1B and Unit 2A essential busses remain energized by their respective EDGs. The licensee does not have an estimate as to when offsite power will be restored for these busses.

Additional information provided as follow-up includes:

4-hour notification per 10CFR50.72(b)(2)(iv)(B) due to the Unit 1 Reactor Protection System [RPS] actuation (Rx Trip),

4-hour notification per 10CFR50.72(b)(2)(xi) for offsite notifications to the States of North and South Carolina and the counties of York, Gaston and Mecklenburg,

8-hour notification per 10CFR50.72(b)(3)iv)(A) due to the Unit 1 Rx Trip, Unit 1 Auxiliary Feedwater automatic start, Unit 1A and 1B and Unit 2A and 2B EDG auto starts.

8-hour notification per 10CFR50.72(b)(3)(v)(B) due to the loss of Residual Heat Removal [RHR] cooling on the initial loss of power. Unit 2 RHR was restored in less than three (3) minutes when the essential busses were re-energized by the EDGs.

The licensee informed the NRC Resident Inspector.

Notified R2IRC, EO (Nelson), IRD (Gott) and FEDS (DHS SWO, DOE Ops Center, FEMA, HHS Ops Center, DHS NICC, USDA Ops Center, EPA EOC) and NuclearSSA via email.

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Power Reactor Event Number: 47806
Facility: QUAD CITIES
Region: 3 State: IL
Unit: [ ] [2] [ ]
RX Type: [1] GE-3,[2] GE-3
NRC Notified By: BRIAN MAGNUSON
HQ OPS Officer: VINCE KLCO
Notification Date: 04/04/2012
Notification Time: 21:32 [ET]
Event Date: 04/04/2012
Event Time: 17:16 [CDT]
Last Update Date: 04/04/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
TAMARA BLOOMER (R3DO)

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

Event Text

DEGRADED CONDITION DUE TO IDENTIFIED REACTOR PRESSURE VESSEL TEST LEAKAGE

"On April 4, 2012, at 1716 [CDT], with Unit 2 shutdown for refueling, leakage was identified from a 2-inch vessel nozzle during a Reactor Pressure Vessel (RPV) pressure test. The leakage amount was approximately one drop per second. The penetration (N-11B) is a reference leg used for reactor vessel instrumentation. The leakage originates from the area where the nozzle penetrates the vessel wall. The nozzle is welded on the inside of the vessel, so the actual attachment weld could not be examined at the time of this report. The RPV pressure test has been stopped and the reactor vessel depressurized. The cause and resolution are under evaluation. The condition is being reported under 50.72(b)(3)(ii)(A) given the defect was associated with the primary coolant system pressure boundary."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47807
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: RON FRY
HQ OPS Officer: PETE SNYDER
Notification Date: 04/04/2012
Notification Time: 22:59 [ET]
Event Date: 04/04/2012
Event Time: 18:35 [EDT]
Last Update Date: 04/04/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
JOHN CARUSO (R1DO)

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

INOPERABLE ACCIDENT MITIGATION EQUIPMENT

"On 4/4/2012 at 1517 EDT, the 'A' Emergency Diesel Generator (EDG) was declared inoperable for performance of a maintenance surveillance. At 1835 EDT on 4/4/2012 the 'B' Control Structure Chiller was declared inoperable due to an unrelated problem. [With] the 'B' Control Structure Chiller inoperable coincident with the 'A' EDG inoperable, the 'A' Control Structure Chiller would not be available to perform its design function on a loss of offsite power. This is a condition that, at the time of discovery, could have prevented fulfillment of a Safety Function and is reportable under 50.73(a)(2)(v) as an 8 hour notification. Note that Technical Specifications allows four hours to correct the condition before further actions are required, i.e. declare the features ('A' Control Structure Chiller) supported by the inoperable diesel inoperable. The 'A' EDG was restored to operable at 2200 which restored safety function capability for the 'A' Control Structure Chiller."


The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Thursday, April 05, 2012
Thursday, April 05, 2012