United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 6, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/05/2012 - 04/06/2012

** EVENT NUMBERS **


47696 47790 47791 47805 47808 47809 47810

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Power Reactor Event Number: 47696
Facility: FORT CALHOUN
Region: 4 State: NE
Unit: [1] [ ] [ ]
RX Type: (1) CE
NRC Notified By: DAVID SPARGO
HQ OPS Officer: CHARLES TEAL
Notification Date: 02/24/2012
Notification Time: 04:24 [ET]
Event Date: 02/23/2012
Event Time: 22:00 [CST]
Last Update Date: 04/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
RICK DEESE (R4DO)

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

Event Text

LOSS OF 21 OUT OF 101 EMERGENCY SIRENS

"Communications has been lost to 21 sirens out of 101. The loss of communications does not allow the activation of the sirens. Almost all of Harrison County and Pottawattamie County in Iowa are without communications to the sirens. There are compensatory measures in place to ensure notification by local law enforcement in case of an actual emergency to inform the public in these areas.

"This is being reported per 10CFR50.72(b)(3)(xiii) for 'Any event that results in a major loss of emergency assessment capability, off site response capability, or communications capability'.

"An attempt is being made to reboot the siren's communication system in order to restore the sirens. During the reboot, sirens in Washington County, Nebraska, will also lose communications and therefore will not be functional. Local Law Enforcement has been notified in Washington County to perform compensatory measures in case of an emergency."

The NRC Resident Inspector has been informed.


* * * UPDATE FROM DAVID SPARGO TO DONALD NORWOOD AT 0621 EST ON 2/24/2012 * * *

"As of 0518 CST, communications has been reestablished and all sirens were returned to service."

The licensee notified the NRC Resident inspector.

Notified R4DO (Deese).

* * * UPDATE FROM ERICK MATZKE TO HOWIE CROUCH AT 1602 EDT ON 04/05/12 * * *

"Following an investigation of the siren failure, it was determined that all sirens were lost for a period of time from approximately 1809 CST February 23, 2012 until 0518 CST February 24, 2012. The control room was notified at 0215 CST February 24, 2012 and compensatory measures were established for all affected counties in Iowa and Nebraska. No new compensatory measures or actions are or were required."

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

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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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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 47791
Rep Org: US ARMY
Licensee: US ARMY
Region: 3
City: WARREN State: MI
County:
License #: 21-32838-01
Agreement: N
Docket:
NRC Notified By: THOMAS GIZICKI
HQ OPS Officer: CHARLES TEAL
Notification Date: 03/30/2012
Notification Time: 15:31 [ET]
Event Date: 12/16/2009
Event Time: [EDT]
Last Update Date: 04/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)
ANGELA MCINTOSH (FSME)
BILLY DICKSON (R3DO)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

MISSING CHEMICAL AGENT DETECTOR

When returning from deployment a Virginia National Guard unit discovered that they had lost a M43A1 Chemical Detector containing 250 uCi of Am-241. The unit searched the facility as well as a storage warehouse located in Richmond, VA for the device, but they were unable to locate it.

* * * RETRACTION FROM THOMAS GIZICKI TO VINCE KLCO ON 4/5/2012 AT 1201 EDT * * *

Retraction due to the detector found in the same location in a different Army unit.

Notified the R1DO (Caruso), R3DO (Bloomer) and the FSME (McIntosh).

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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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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General Information Event Number: 47808
Rep Org: BUREAU OF INDIAN AFFAIRS
Licensee: UNKNOWN
Region: 3
City: ASHLAND State: WI
County:
License #: 48-32735-01
Agreement: Y
Docket:
NRC Notified By: JEFF BRADLEY
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/05/2012
Notification Time: 10:45 [ET]
Event Date: 04/05/2012
Event Time: 09:00 [CDT]
Last Update Date: 04/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
TAMARA BLOOMER (R3DO)
ANGELA MCINTOSH (FSME)

This material event contains a "Less than Cat 3" level of radioactive material.

Event Text

TROXLER MOISTURE DENSITY GAUGE FOUND ON INDIAN RESERVATION

The Bureau of Indians Affairs Great Lakes Agency (License #48-32735-01) reported that a Troxler Moisture Density Gauge has been found on the Bad River Indian Reservation. The gauge was delivered to the Radiation Safety Officer for the Bureau of Indian Affairs. The gauge is currently stored in a safe location and the source rod is in the locked position. The licensee and owner of the gauge is not known at this time. The Troxler Gauge is a model 3411B, S/N 8975, and contains an Am-241 40 mCi and a Cs-137 7.5 mCi source. The RSO contacted the Troxler Corporation for more information.

THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Power Reactor Event Number: 47809
Facility: FARLEY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: ALTON DEWEESE
HQ OPS Officer: VINCE KLCO
Notification Date: 04/05/2012
Notification Time: 18:21 [ET]
Event Date: 04/05/2012
Event Time: 12:20 [CDT]
Last Update Date: 04/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
GERALD MCCOY (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

UNPLANNED SYSTEMS ACTUATIONS WHILE PERFORMING A SURVEILLANCE TEST

"Unit 1 was performing a planned refueling outage surveillance test, FNP-1-STP-40.0, 'Safety Injection with Loss of Off-Site Power [LOSP].' The systems were being returned to normal following the actuation portion of the test. When the B1F Sequencer Test Trip Override Switch was taken to the 'ON' position, the 1-2A Diesel Generator output breaker opened, which caused a loss of power to the 'A' Train 4 kV busses. Prior to the event, the 1-2A Diesel Generator was running at normal speed and voltage carrying the 'A' Train 4kV busses. When the diesel generator output breaker opened, it then reclosed upon receipt of the LOSP signal causing the LOSP sequencer loads to automatically start. This included the 1C Component Cooling Water Pump, the 1A High Head Safety Injection Pump (discharge isolation was closed prior to the event), and the 1A and 1B SW pumps. Therefore, during the test, the system actuated in a way that was not part of the planned surveillance testing. The 1A RHR pump was in shutdown cooling mode at the time of the event and was load shed. RHR was restarted manually by the operating crew approximately 1 minute later (no auto start [signal] present due to a loss of site power - LOSP signal without a safety injection signal present).

"The investigation revealed that a step in the procedure sequence was not performed during the restoration portion of the test. The operator did not parallel the diesel with off-site power prior to operating the B1F Sequencer Test Trip Override Switch which opened the diesel output breaker without off-site power aligned to the 'A' Train 4kV busses. The 1-2A Diesel Generator was subsequently paralleled to the grid and properly shutdown per the test procedure restoration."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47810
Facility: OCONEE
Region: 2 State: SC
Unit: [ ] [2] [ ]
RX Type: [1] B&W-L-LP,[2] B&W-L-LP,[3] B&W-L-LP
NRC Notified By: STEPHEN NEWMAN
HQ OPS Officer: PETE SNYDER
Notification Date: 04/06/2012
Notification Time: 03:57 [ET]
Event Date: 04/05/2012
Event Time: 22:38 [EDT]
Last Update Date: 04/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
GERALD MCCOY (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 N Y 100 Power Operation 85 Power Operation

Event Text

STANDBY SHUTDOWN FACILITY (SSF) NOT ANALYZED FOR ALL OPERATING CONDITIONS

"On 3/29/2012 Duke Energy identified that unanalyzed conditions exist for SSF mitigated events since associated thermal and hydraulic analyses do not consider all initial operating conditions, especially lower operating modes and lower decay heat. Specifically there are four (4) conditions where the SSF is not currently analyzed:

"1. SSF operating at less than 525 degrees F and less than normal operating pressure (approximately 2155 psig),
2. SSF operation before four (4) Effective Full Power Days (EFPDs),
3. SSF reactor coolant make up at low Reactor Coolant System (RCS) pressure.
4. A reactor trip from less than 85 percent power and less than 579 degrees F.

"On 4/4/2012, an immediate determination of operability concluded that for the first three (3) conditions the SSF was operable but degraded/nonconforming (OBDN). For the 4th issue, there was reasonable assurance that 1% delta k/k shutdown margin would be maintained if T ave. remained above 500 degrees F. Based on a lack of analysis and an increased likelihood of reducing T ave. below 525 degrees F during a 72 hour event, the SSF was declared OBDN with a separate operability determination required to validate the Unit 3 power coastdown and end of life T ave. reduction analysis. Until additional analysis is performed, the SSF is inoperable on any unit where the power level is reduced below 85 percent.

"A second operability determination for Unit 3 concluded that the SSF will maintain greater than or equal to 525 degrees F with an initial power level of 70 percent and a 570 degree F T ave. The SSF will be declared inoperable on Unit 3 if power is reduced to less than 70 percent. Seventy percent was chosen as a conservative value to ensure the unit stayed inside the bounds of existing analyses. Unit 3 is currently at approximately 85 percent power and reducing power at approximately 1 percent per day in preparation for the Unit 2 end of core 26 refueling outage. For Unit 3, the SSF is OBDN based on preliminary calculation results.

"On 4/5/2012, due to a worsening component cooling water system leak on Unit 2, it was necessary to bring the unit down to Mode 3 to implement repairs. Upon down power, when Unit 2 transitioned below 85 percent power, the ability of the SSF to perform its design function, in consideration of the information above, could not be confirmed and the SSF was declared inoperable for Unit 2.

"Currently, there is no conclusive information that would support SSF operability while Unit 2 is below 85 percent power. As such, this event is being conservatively reported under 50.72(b)(3)(ii)(B), 'The nuclear plant being in an unanalyzed condition that significantly degrades plant safety.' Due to their current power levels, this condition does not affect Units 1 and 3.

"Initial Safety Significance: Until confirmed by analysis, the lack of decay heat may result in an initial over cooling of the RCS and potentially an interruption of natural circulation or inadequate shutdown margin. Consequently, the SSF was declared inoperable.

"Corrective Action(s): Additional analyses are being completed to reestablish SSF operability to bound the unanalyzed entry conditions.

"The NRC Resident Inspector has been informed."

Page Last Reviewed/Updated Friday, April 06, 2012
Friday, April 06, 2012