United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 12, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/11/2012 - 04/12/2012

** EVENT NUMBERS **


47599 47820 47821 47822 47823 47824 47825 47826 47827 47828

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Non-Agreement State Event Number: 47599
Rep Org: AVERA MCKENNAN HOSPITAL
Licensee: AVERA MCKENNAN HOSPITAL
Region: 4
City: SIOUX FALLS State: SD
County: MINNEHAHA
License #: 4016571-01
Agreement: N
Docket:
NRC Notified By: RICHARD MASSOTH
HQ OPS Officer: VINCE KLCO
Notification Date: 01/17/2012
Notification Time: 13:04 [ET]
Event Date: 01/16/2012
Event Time: 16:00 [MST]
Last Update Date: 04/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
GREG PICK (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT DUE TO POTENTIAL DIFFERENT FRACTIONAL DOSE DELIVERED THAN PRESCRIBED

The licensee provided notification that a patient received 2 occurrences of a dose less than prescribed when delivering ten fractions of a treatment. Each of the underdoses were approximately 50% of the 340 Gray prescribed fractional dose. The patient will receive additional dose fractions in order to achieve the written directive total dose. The Radiation Oncologist has notified the patient and attending physician.

* * UPDATE FROM RICHARD MASSOTH TO JOHN KNOKE AT 1826 EST ON 01/31/12 * *

"On January 17, 2012 the NRC Operations Center was verbally notified of two Therapeutic Underdose Occurrences discovered by the licensee on January 16 and 17, 2012. These occurrences involved a fractionated Breast High Dose Rate Afterloader (HDR) treatment with a SenoRx Contura multicatheter breast applicator. The first and third delivered treatment fractions were found to be less than 50% of the intended fractional dose. The entire course of the treatment in the written directive included ten equal-dose fractions of 3.4 Gray per fraction for a total dose of 34 Gray to the prescribed treatment site. To correct for the underdose occurrences, two additional treatment fractions were added and the treatment plan was modified to achieve the total dose specified in the written directive.

"The licensee now believes that this medical event has also caused an unintended dose to skin outside of the prescribed treatment site, requiring notification under 10CFR35.3045(a)(3). The licensee has performed computer simulation, calculations and physical measurements using TLDs simulating the treatment geometry to model the unintended skin dose. The event delivered an unintended skin dose exceeding at least the skin erythema threshold (2 Gy). The licensee is continuing to monitor the patient response to the skin dose and is working to refine the unintended skin dose estimates. An NRC reactive inspection team is on-site."

Notified R4DO (Jeff Clark) and FSME (Greg Suber)

* * * UPDATE FROM TRACI HOLLINGSHEAD TO HOWIE CROUCH AT 1044 EDT ON 4/12/12 * * *

The licensee confirmed that they agree with their medical consultants' findings that the patient received approximately 2720 rads of unintended skin dose.

Notified R4DO (Gaddy) and FSME (McIntosh).

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: 47820
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: ALEX MCLELLAN
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/11/2012
Notification Time: 01:18 [ET]
Event Date: 04/10/2012
Event Time: 21:48 [EDT]
Last Update Date: 04/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
BLAKE WELLING (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

SPDS AND ERDS REMOVED FROM SERVICE DUE TO PLANNED MAINTENANCE

"At 2148 EDT, on April 10, 2012 the Unit 1 & Unit 2 Safety Parameter Display System (SPDS) and Emergency Response Data System (ERDS) system was removed from service to support a planned maintenance outage on the 1A Engineered Safeguards System (ESS) Bus as part of the U1 17th Refueling and Inspection outage. The Bus Outage is expected to have a duration greater than 8 hours, but less than 72 hours. During this time, required control room hardwire indications will be available from the unaffected ESS buses. An update will be provided when SPDS/ERDS becomes available.

"Since the Unit 1 & Unit 2 SPDS/ERDS computer system will be unavailable for greater than 8 hours, this is considered a Loss of Emergency Assessment Capability and reportable under 10 CFR50.72(b)(3)(xiii)."

The licensee has notified the NRC Resident Inspector.

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Non-Agreement State Event Number: 47821
Rep Org: SINAI-GRACE HOSPITAL
Licensee: SINAI-GRACE HOSPITAL
Region: 3
City: DETROIT State: MI
County:
License #: SNM-1991
Agreement: N
Docket:
NRC Notified By: TIM APPLEGATE
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/11/2012
Notification Time: 11:15 [ET]
Event Date: 01/31/2012
Event Time: [EDT]
Last Update Date: 04/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAVID HILLS (R3DO)
ANGELA MCINTOSH (FSME)

This material event contains a "Category 3" level of radioactive material.

Event Text

PATIENT BURIED WITH PLUTONIUM-238 PACEMAKER

A former patient at St. John Macomb-Oakland Hospital expired on 1/31/12 and the body was released to the family for burial. The patient had a Medtronic pacemaker with a radionuclide of Plutonium-238. The RSO at Sinai-Grace Hospital notified the NRC of this event.

There is no planned action to recover the pacemaker from the buried patient.


THIS MATERIAL EVENT CONTAINS A "CATEGORY 3" LEVEL OF RADIOACTIVE MATERIAL

Category 3 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 some hours. It could possibly - although it is unlikely - be fatal to be close to this amount of unshielded radioactive material for a period of days to weeks. These sources are typically used in practices such as fixed industrial gauges involving high activity sources (for example: level gauges, dredger gauges, conveyor gauges and spinning pipe gauges) and well logging. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

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Non-Agreement State Event Number: 47822
Rep Org: SABIC INNOVATIVE PLASTICS
Licensee: SABIC INNOVATIVE PLASTICS
Region: 3
City: MT. VERNON State: IN
County:
License #: GL
Agreement: N
Docket:
NRC Notified By: RANDY BOYER
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/11/2012
Notification Time: 16:02 [ET]
Event Date: 03/22/2012
Event Time: 09:30 [EDT]
Last Update Date: 04/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
20.2201(a)(1)(i) - LOST/STOLEN LNM>1000X
Person (Organization):
DAVID HILLS (R3DO)
ANDREW PERSINKO (FSME)
ILTAB via EMAIL ()

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

Event Text

SIX TRITIUM EXIT SIGNS UNACCOUNTED FOR AFTER SHIPPING TO MANUFACTURER

On 1/16/12, the licensee replaced the tritium exit signs in their facility. These exit signs were installed in the late 60's. They put the signs back into the original packaging to return them to the manufacturer. Gexpro [exit sign distributors] picked up the signs with the understanding that they would be shipped to SRB Technologies Inc. (the sign manufacturer). SRB technologies did not receive the signs. A search of the Gexpro warehouse did not locate the signs. Additionally, SRB Technologies had no record of receiving the signs.

A total of 6 tritium exit signs are unaccounted for. The serial numbers of the signs are 600275, 600276, 600277, 600278, and 600279. The remaining exit sign did not have a serial number attached any longer.

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: 47823
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: PAUL MARVEL
HQ OPS Officer: STEVE SANDIN
Notification Date: 04/11/2012
Notification Time: 16:32 [ET]
Event Date: 03/19/2012
Event Time: 03:00 [EST]
Last Update Date: 04/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
BLAKE WELLING (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

OFFSITE NOTIFICATION TO STATE AND LOCAL AGENCIES DUE TO NPDES DISCHARGE

"The following ENS is being submitted late.

"On Monday, March 19, 2012 at 3 a.m. a manhole overflowed during a scheduled and permitted radiological release through the cooling tower blow down outfall. As a result, several thousand gallons of water overflowed briefly, formed puddles in the area, and was discharged through a different National Pollutant Discharge Elimination System (NPDES) permitted outfall.

"The overflow was terminated, water samples were collected from the impacted areas, and the area was remediated in keeping with the Station's environmental monitoring program. Several samples showed increased levels of tritium that were well below permitted Commonwealth and Federal effluent limits.

"There were no public health risks associated with this event. The NRC Resident Inspector was notified, and courtesy notifications were made to all appropriate government agencies and local stakeholders in accordance with NEI 07-07, Industry Groundwater Protection Initiative, on March 20, 2012. Due to notification of government agencies, this event is being reported under 10CFR50.72 (b)(2)(xi)."

The licensee informed the Commonwealth of Pennsylvania, and Berks, Montgomery and Chester counties.

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Power Reactor Event Number: 47824
Facility: ARKANSAS NUCLEAR
Region: 4 State: AR
Unit: [1] [2] [ ]
RX Type: [1] B&W-L-LP,[2] CE
NRC Notified By: STEVEN COFFMAN
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/11/2012
Notification Time: 17:02 [ET]
Event Date: 04/11/2012
Event Time: 12:40 [CDT]
Last Update Date: 04/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
VINCENT GADDY (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

DRILL MESSAGE INADVERTENTLY MISTAKEN FOR ACTUAL EVENT

"As part of a planned NRC Emergency Plan Exercise on 04/11/2012, local radio and television stations were given access to drill exercise messages to facilitate public awareness of the drill. These messages were plainly marked as 'drill' activity. At 12:40 p.m. CST, an email was sent to Entergy Executive Management showing the contents of a web page that stated in part 'A site area emergency was declared Wednesday at Arkansas Nuclear One, Unit 1, today at 10:18 a.m. by Entergy Operations Inc. officials...' A Little Rock, Arkansas local television station had posted a story on their internet web page at 10:53 a.m., indicating a real event, not a drill activity. The television station News Director stated that once the error was identified, the story was removed from their web page within a matter of minutes. This unplanned media event is being reported in accordance with 10CFR 50.72.(b)(2)(xi)."

The NRC Resident Inspector has been informed.

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Power Reactor Event Number: 47825
Facility: GRAND GULF
Region: 4 State: MS
Unit: [1] [ ] [ ]
RX Type: [1] GE-6
NRC Notified By: SCOTTY BEACH
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/11/2012
Notification Time: 20:03 [ET]
Event Date: 04/11/2012
Event Time: 18:26 [CDT]
Last Update Date: 04/11/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
VINCENT GADDY (R4DO)
ELMO COLLINS (RA)
BRUCE BOGER (NRR)
JOSEPH GIITTER (NRR)
WILLIAM GOTT (IRD)

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

Event Text

UNUSUAL EVENT DUE TO A FIRE IN THE 'A' MAIN CONDENSER

"At 1811 [CDT] hours a fire was reported inside the 'A' Main Condenser. The fire brigade was dispatched to combat the fire and the area was evacuated.

"An Unusual Event (HU4) was declared at 1826 [CDT] hours due to the fire being in the Protected Area boundary and not extinguished within 15 minutes of detection.

"The Claiborne County, Mississippi Fire Department was notified to provide assistance.

"At 1847 [CDT] hours the fire was reported to be extinguished.

"The Unusual Event was terminated at 1900 [CDT] hours."

The source of the fire is still under investigation. There were no personnel injuries.

The licensee notified the NRC Resident Inspector, Mississippi Emergency Management, Governor Office of Homeland Security, Claiborne County Sheriffs Department, Tensas Sheriffs Office, Mississippi Highway Patrol, and the Louisiana Department of Environmental Quality.

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

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Power Reactor Event Number: 47826
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: JEFF GROFF
HQ OPS Officer: CHARLES TEAL
Notification Date: 04/11/2012
Notification Time: 22:38 [ET]
Event Date: 04/11/2012
Event Time: 18:07 [EDT]
Last Update Date: 04/11/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(B) - POT RHR INOP
Person (Organization):
DAVID HILLS (R3DO)

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

Event Text

BRIEF LOSS OF RHR PUMP DUE TO VOLTAGE TRANSIENT

"On 4/11/12 at 1807 EDT, with the plant shutdown in Mode 5 during Refueling Outage 15, the 'A' Residual Heat Removal pump tripped while operating in the Shutdown Cooling Mode. The pump trip was due to an isolation of the E1150F009 'Division 1 RHR Shutdown Cooling Inboard Isolation Valve.' This resulted in an interruption of primary decay heat removal for approximately 11 minutes. Approximate calculated time to boil was 23.1 hours. This is being reported under 10CFR50.72(b)(3)(v)(B) 'Any event or condition that at the time of discovery could have prevented the fulfillment of the safety function of structures or systems that are needed to remove residual heat.'

"At the time of the pump trip, the station was attempting to restore power to Division 2 Bus 65E from the 64T cross tie bus. A voltage transient occurred due to a fault and caused a Group 4 (Shutdown Cooling/Head Spray) isolation signal. Abnormal Operating Procedure 20.205.01 'Loss of Shutdown Cooling,' was entered, the Group 4 isolation was reset and Shutdown Cooling was restored at 1818 EDT.

"An investigation is in progress to determine the cause of the bus fault."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 47827
Facility: TURKEY POINT
Region: 2 State: FL
Unit: [3] [ ] [ ]
RX Type: [3] W-3-LP,[4] W-3-LP
NRC Notified By: DAVID BROOKINS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/12/2012
Notification Time: 07:28 [ET]
Event Date: 04/11/2012
Event Time: 10:48 [EDT]
Last Update Date: 04/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

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

Event Text

FITNESS FOR DUTY - A CONTRACT SUPERVISOR TESTED POSITIVE ON A DRUG TEST

A non-licensed contract supervisor tested positive for illegal drugs on a random fitness-for-duty test. The individual's access has been terminated. Contact the Headquarters Operations Officer for additional details.

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Power Reactor Event Number: 47828
Facility: ROBINSON
Region: 2 State: SC
Unit: [2] [ ] [ ]
RX Type: [2] W-3-LP
NRC Notified By: GEORGE CURTIS
HQ OPS Officer: HOWIE CROUCH
Notification Date: 04/12/2012
Notification Time: 09:42 [ET]
Event Date: 04/12/2012
Event Time: 09:30 [EDT]
Last Update Date: 04/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
KATHLEEN O'DONOHUE (R2DO)

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

Event Text

TSC AND EOF OUT OF SERVICE DUE TO MAINTENANCE

"At approximately 0930 hours EDT on Thursday, April 12, 2012, the H. B. Robinson Steam Electric Plant, Unit No. 2, Technical Support Center (TSC)/Emergency Response Facility (EOF) air conditioning and charcoal filtration systems will be removed from service to facilitate the replacement of the charcoal filtration media. The duration of work is expected to be approximately 11 hours. Since the unavailability will last greater than 8 hours, this is considered a Loss of Emergency Assessment Capability, and reportable under 10 CFR 50.72(b)(3)(xiii).

"Due to the inability of the TSC/EOF ventilation system to maintain a habitable atmosphere, as a compensatory measure, Emergency Responders assigned to these facilities have been informed to report to the alternate facilities until such time that the TSC/EOF ventilation system has been returned to service.

"TSC/EOF ventilation system maintenance and post maintenance testing is scheduled to be completed by 2030 hours EDT on Thursday April 12, 2012.

"The NRC Resident Inspector has been informed."

Page Last Reviewed/Updated Thursday, April 12, 2012
Thursday, April 12, 2012