United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 20, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/19/2012 - 04/20/2012

** EVENT NUMBERS **


47722 47832 47833 47839 47850 47851 47852 47853 47854 47855

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Non-Agreement State Event Number: 47722
Rep Org: INDIANA UNIVERSITY MEDICAL CENTER
Licensee: INDIANA UNIVERSITY MEDICAL CENTER
Region: 3
City: INDIANAPOLIS State: IN
County:
License #: 13-02752-03
Agreement: N
Docket:
NRC Notified By: MACK RICHARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 03/07/2012
Notification Time: 14:45 [ET]
Event Date: 07/05/2011
Event Time: [EST]
Last Update Date: 04/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
MARK RING (R3DO)
ANGELA MCINTOSH (FSME)

Event Text

MEDICAL EVENT - DOSAGE DELIVERED TO PATIENT DIFFERED BY 20% FROM PRESCRIBED DOSAGE

On 7/5/11 a male patient receiving treatment for prostate cancer was supposed to receive 52 Iodine-125 seeds to the prostate. The physician conducting the surgery injected 21 of the 52 seeds to an area outside the target volume. Only 31 of the 52 seeds were injected into the targeted area.

The physician and patient will be advised of the disparity in dosage.

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.

* * * RETRACTION AT 1100 EST ON 4/19/12 FROM RICHARD TO SIMPSON * * *

The licensee is retracting this event report after a review and evaluation of the doses administered. The licensee has determined that this event is not reportable based on the delivered dose not differing by 20% from the prescribed dosage and is therefore not reportable under 10 CFR 35.3045.

The licensee has discussed this conclusion with NRC Region 3 (Warren).

R3DO (Peterson) and FSME (McIntosh) have been notified.

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Agreement State Event Number: 47832
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: UNIVERSITY OF TEXAS MD ANDERSON CANCER
Region: 4
City: HOUSTON State: TX
County:
License #: 00466
Agreement: Y
Docket:
NRC Notified By: ART TUCKER
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/13/2012
Notification Time: 13:35 [ET]
Event Date: 04/11/2012
Event Time: [CDT]
Last Update Date: 04/13/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
VINCENT GADDY (R4DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE TO PATIENT RECEIVING YTTRIUM-90 MICROSPHERES TREATMENT

The following information was sent by the State of Texas via email:

"On April 13, 2012, the Agency [Texas Department of Health] was notified by the licensee that a therapy event had occurred on April 11, 2012. A patient was prescribed 105 grays using Yttrium-90 microspheres. The patient received only 77.4 grays. The licensee stated that the reduced exposure was because a flow clamp was not in the fully opened position allowing microspheres to plate out in the flow tube instead of being administered to the patient. The licensee stated that there were no adverse effects on the patient.

"Additional information will be provided as it is received in accordance with SA-300."

Texas Report No: I-8948

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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Part 21 Event Number: 47833
Rep Org: MITSUBISHI NUCLEAR ENERGY SYSTEMS
Licensee: MITSUBISHI HEAVY INDUSTRIES, LTD
Region: 1
City: ARLINGTON State: VA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: EI KADOKAMI
HQ OPS Officer: JOHN KNOKE
Notification Date: 04/13/2012
Notification Time: 15:58 [ET]
Event Date: 04/13/2012
Event Time: [EDT]
Last Update Date: 04/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(a)(2) - INTERIM EVAL OF DEVIATION
Person (Organization):
BLAKE WELLING (R1DO)
KATHLEEN O'DONOHUE (R2DO)
DAVID HILLS (R3DO)
VINCENT GADDY (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 INTERIM REPORT - STEAM GENERATOR TUBE WEAR

This interim Part 21 is in regard to San Onofre Nuclear Generating Station, Unit 2, Steam Generator replacement.

"During the first refueling outage following steam generator replacement, eddy current testing identified ten total tubes with depths of 90 to 28 percent of the tube wall thickness. Some of the affected tubes were located adjacent to retainer bars. The retainer bars are part of the floating anti-vibration bar (AVB) structure that stabilizes the u-bend region of the tubes.

"Other tubes in the two steam generators had detectable wear associated with support points elsewhere in the AVB structure. Each steam generator has 9727 tubes with an 8 percent (778 tubes) design margin for tube plugging.

"Discovery Date: February 13, 2012

"Evaluation completion schedule date: May 31, 2012"

"Those Mitsubishi Heavy Industries customers potentially affected by this issue have been notified and will receive a copy of this interim report."

Reference Document: UET-20120089
Interim Report No: U21-018-IR (0)

* * * UPDATE FROM JOSEPH TAPIA TO KARL DIEDERICH ON 4/19/12 AT 1306 EDT * * *

"On January 31, 2012, San Onofre Unit 3 shut down due to indications of a steam generator [SG] tube leak. Steam generator tube inspections confirmed one small leak on one tube in one of the two steam generators. Continuing inspections of 100% of the steam generator tubes in both Unit 3 steam generators discovered unexpected wear, including tube to tube as well as tube to tube support structural wear. Inspection, testing, and analysis of SG tube integrity in both Unit 3 SGs is ongoing. In-situ pressure testing identified eight Unit 3 SG tubes that did not meet the target performance criteria in Technical Specification for tube integrity. One of the failed tubes was the leaking tube that required the Unit 3 shutdown.

"Discovery date: February 21, 2012

"Evaluation completion schedule date: August 31, 2012"

Notified R1DO (Joustra), R2DO (Nease), R3DO (Peterson), R4DO (O'Keefe), and Part 21 Group via email.

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Agreement State Event Number: 47839
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: CLOSE THE LOOP, INC.
Region: 1
City: HEBRON State: KY
County:
License #: 401-865-430
Agreement: Y
Docket:
NRC Notified By: CHRISTOPHER KEFFER
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/16/2012
Notification Time: 14:22 [ET]
Event Date: 04/13/2012
Event Time: 07:00 [CDT]
Last Update Date: 04/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
ANGELA MCINTOSH (FSME)

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

Event Text

LOST STATIC ELIMINATOR

The licensee notified the Kentucky Department of Public Health and Safety, Radiation Health Branch on April 16, 2012 at 1135 (CDT) of a missing static eliminator. The static eliminator was discovered to be missing by an oncoming operator on April 13, 2012 at 0700 (CDT). An operator on the previous shift reported the device to be in place. The Director of Facility Operations was not in the office on April 13, 2012 and was not made aware of the missing device until April 16, 2012 at 0715 (CDT). The licensee initiated a search for the device on April 16, 2012 at 0715 (CDT) but has been unsuccessful in locating the device. The licensee plans to continue searching for the device. The licensee does not suspect tampering or theft and no exposures to personnel have occurred or are expected at this time. The device is a Model P-2021 Static Eliminator, Serial # A2HU670, with a 10 mCi Po-210 source.

Kentucky Radiation Health Branch Report number KY120007.

No other notifications have been made by the licensee.

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

Note: This device is assigned an IAEA Category 3 value based on the actual radioactivity of the source, not on the device type. (Reference IAEA RG-G-1.9)

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Power Reactor Event Number: 47850
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: BRANDON SHULTZ
HQ OPS Officer: KARL DIEDERICH
Notification Date: 04/19/2012
Notification Time: 11:10 [ET]
Event Date: 04/19/2012
Event Time: 07:53 [EDT]
Last Update Date: 04/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
JUDY JOUSTRA (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 M/R Y 100 Power Operation 0 Hot Shutdown

Event Text

MANUAL REACTOR SCRAM FOLLOWING LOSS OF RECIRCULATION PUMPS

"Limerick Unit 1 was manually scrammed from 100% power at 0753 hours on 4/19/12 in accordance with plant procedure OT-112 'Recirculation Pump Trip' when both 1A and 1B Recirculation Pump Adjustable Speed Drives (ASDs) tripped due to an electrical fault affecting the 144D and 114A non-safety related 480V Load Centers. The shutdown was normal and the plant is stable in Hot Shutdown with normal pressure control via the Main Steam Bypass valves to the main condenser and normal level control using feedwater. The manual RPS actuation is reportable under 10 CFR 50.72(b)(2).

"The Technical Support Center (TSC) Normal Air conditioning systems shut down due to loss of power from the 144D Load Center. The loss of power also affects the flow indication for the Emergency Ventilation system. This is considered a Loss of Emergency Assessment Capability, and reportable under 10 CFR 50.72(b)(3)(xiii). The Emergency TSC Ventilation system is available but flow cannot be verified. During a required activation the TSC, responders would report to the TSC. If conditions required use of the Emergency Ventilation system, the Station Emergency Director would assess habitability in accordance with Station procedures. TSC relocation of personnel would be directed as required until such time that the TSC ventilation system is returned to service"

The licensee notified the NRC Resident Inspector.

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Fuel Cycle Facility Event Number: 47851
Facility: GLOBAL NUCLEAR FUEL - AMERICAS
RX Type: URANIUM FUEL FABRICATION
Comments: LEU CONVERSION (UF6 TO UO2)
                   LEU FABRICATION
                   LWR COMMERICAL FUEL
Region: 2
City: WILMINGTON State: NC
County: NEW HANOVER
License #: SNM-1097
Agreement: Y
Docket: 07001113
NRC Notified By: SCOTT MURRAY
HQ OPS Officer: ERIC SIMPSON
Notification Date: 04/19/2012
Notification Time: 13:30 [ET]
Event Date: 04/18/2012
Event Time: 13:45 [EDT]
Last Update Date: 04/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
70.50(b)(2) - SAFETY EQUIPMENT FAILURE
Person (Organization):
REBECCA NEASE (R2DO)
DENNIS DAMON (NMSS)

Event Text

LOCAL ALARM HORN WAS FOUND TO BE INAUDIBLE DURING ROUTINE TESTING

"At approximately 1345 EDT on 4/18/12, during routine testing on an outdoor Criticality Accident Alarm System (CARS) Data Acquisition Module (DAM #22), the local alarm horn in the Wilmington Field Services Center (WFSC) building #3 inspection records area was found to be inaudible. The cause and extent of the condition is under investigation.

"Personnel were removed from the inspection records area until compensatory measures were established. There are no active fissile material operations impacted by this discovery, thus no unsafe condition existed.

"This event is being reported pursuant to the requirements of 10CFR70.50 (b)(2)."

The licensee notified the NC Division of Radiation Protection and the New Hanover County Emergency Response Center.

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Power Reactor Event Number: 47852
Facility: BEAVER VALLEY
Region: 1 State: PA
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: DAN SCHWER
HQ OPS Officer: BILL HUFFMAN
Notification Date: 04/19/2012
Notification Time: 17:47 [ET]
Event Date: 04/19/2012
Event Time: 11:58 [EDT]
Last Update Date: 04/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xii) - OFFSITE MEDICAL
Person (Organization):
JUDY JOUSTRA (R1DO)

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

Event Text

OFFSITE TRANSPORT OF POTENTIALLY CONTAMINATED INJURED WORKER

"At approximately 1156 EDT on 4/19/2012, a craft contractor worker was transported to an off-site medical facility due to a work-related injury. The injured individual was partially surveyed by a Health Physics technician in their anti-contamination clothing prior to leaving the site and no radioactive contamination was detected. The injured individual was then transported by ambulance accompanied by a Health Physics technician to the local hospital for medical treatment.

"At the hospital, the individual and applicable areas and equipment were surveyed by the Health Physics technician and no radioactive contamination was detected. The individual's anti-contamination clothing was returned to the site.

"This notification is being made under the 10CFR50.72(b)(3)(xii) reporting requirements since a complete survey of the injured individual was unable to be made and he was considered to be potentially contaminated prior to being transported offsite.

"The site NRC Resident Inspector has been notified."

The worker was in containment on a polar crane platform when injured. He was subsequently released from the hospital and cleared to work.

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Power Reactor Event Number: 47853
Facility: BROWNS FERRY
Region: 2 State: AL
Unit: [1] [ ] [ ]
RX Type: [1] GE-4,[2] GE-4,[3] GE-4
NRC Notified By: RODNEY NACOSTE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/19/2012
Notification Time: 20:58 [ET]
Event Date: 04/19/2012
Event Time: 14:30 [CDT]
Last Update Date: 04/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
REBECCA NEASE (R2DO)

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

HPCI FAILED TRIP TESTING SURVEILLANCE

"On 04/19/12 at 1430 while performing 1-SR-3.5.1.7, HPCI [High Pressure Coolant Injection] Main & Booster Pump Set developed head & flow rate at rated reactor pressure. The HPCI turbine failed to trip using the manual trip pushbutton. This manual trip pushbutton should have caused the 1-FCV-73-18, HPCI TURBINE STOP VALVE, to go closed. HPCI was secured by taking the 1-FCV-73-16, HPCI TURBINE STEAM SUPPLY VALVE, to close. The 1-FCV-73-18, HPCI TURBINE STOP VALVE, also failed to go closed locally using the 1-XCV-73-18, HPCI TURBINE MECHANICAL TRIP, nor did it go closed when the auxiliary oil pump was secured.

"With the 1-FCV-73-18, HPCI TURBINE STOP VALVE, open, the HPCI ramp generator is no longer in the circuit therefore, should an initiation occur and cause the 1-FCV-73-16, HPCI TURBINE STEAM SUPPLY VALVE, to open there is the potential for the HPCI turbine to over speed. Therefore, HPCI was isolated using 1-FCV-73-3, HPCI STEAM LINE OUTBD ISOL VALVE. This incident is reportable as an 8-hour ENS notification under 10CFR 50,72 (b)(3)(v) as '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 mitigate the consequences of an accident.'

"It also requires a 60 day written report in accordance with 10CFR 50.73(a)(2)(vii).

"The NRC Resident Inspector has been notified."

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Power Reactor Event Number: 47854
Facility: MCGUIRE
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: RICK JACKSON
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/19/2012
Notification Time: 22:07 [ET]
Event Date: 04/19/2012
Event Time: 17:45 [EDT]
Last Update Date: 04/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
Person (Organization):
REBECCA NEASE (R2DO)

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

POTENTIAL FIRE INDUCED SPURIOUS OPERATION OF STEAM GENERATOR PORV BLOCK VALVES

"On March 22, 2012, McGuire Nuclear Station notified the NRC of a condition which could result in fire induced spurious operation of the block valves for the Unit 2 Steam Generator (SG) Power Operated Relief Valves (PORVs). This potential condition could adversely affect the ability to achieve and maintain a cold shutdown of Unit 2. This represented a condition reportable as per the requirements of 10 CFR 50.72(b)(3)(ii)(B). Reference Event #47764 [for Unit-2].

"In accordance with 10 CFR 50.72(c)(2)(i), McGuire is reporting results of ensuing cause and extent of condition evaluation of Event #47764, which has identified a similar condition on McGuire Unit 1. This condition could result in a fire induced spurious operation of the block valves for the Unit 1 SG PORVs. This spurious operation could potentially damage these valves and render them inoperable. Since these valves are unisolable, they could not be repaired to allow the Unit 1 SGs to be used for Unit cool down if needed. This potential condition could adversely affect the ability of the plant to achieve and maintain a cold shutdown of Unit 1. This represents a condition reportable as per the requirements of 10 CFR 50.72(b)(3)(ii)(B). This potential condition is mitigated by existing compensatory measures (i.e. fire watches) which have been in place as part of McGuire's transition to NFPA 805."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 47855
Facility: HARRIS
Region: 2 State: NC
Unit: [1] [ ] [ ]
RX Type: [1] W-3-LP
NRC Notified By: ADAM HELSEL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/19/2012
Notification Time: 22:32 [ET]
Event Date: 04/19/2012
Event Time: 17:24 [EDT]
Last Update Date: 04/19/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
REBECCA NEASE (R2DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 N Y 90 Power Operation 90 Power Operation

Event Text

TSC VENTILATION INOPERABLE

"At approximately 1724 EDT on April 19, 2012 with the Harris Nuclear Plant operating at 90% power in mode 1, Air Handler 17 was discovered not operating. Air Handler 17 provides ventilation supporting environmental habitability to the Technical Support Center (TSC) to keep ambient temperatures habitable for personnel and to ensure communications and assessment equipment remains functional. This degrades the heating and cooling capacity of the TSC by approximately one third. Due to the cool weather in the forecast, the remaining cooling systems will be operating more efficiently than they would in the hot summer months, which mitigates the impact of the degraded ventilation system. The system has been repaired as of 1950 EDT on April 19, 2012. The cause of the equipment failure was a broken belt and a condition report has been entered into the site's corrective action program. This report is being made in accordance with 10 CFR 50.72, criterion (b)(3)(xiii) as a condition that may impair the functionality of an Emergency Response Facility. The plant continues to operate at 90%. Other equipment functioned as expected. The on call Emergency Response Manager and Site Emergency Coordinator (TSC) have been notified and the alternate TSC is available."

The licensee notified the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, April 20, 2012
Friday, April 20, 2012