United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for June 8, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
06/07/2012 - 06/08/2012

** EVENT NUMBERS **


47816 47844 47980 47982 47983 48000 48001 48002 48004 48005

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 47816
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: MARK ABRAMOVITZ
Notification Date: 04/09/2012
Notification Time: 02:07 [ET]
Event Date: 04/09/2012
Event Time: 01:02 [EDT]
Last Update Date: 06/07/2012
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

BOTH CONTROL STRUCTURE CHILLERS DECLARED INOPERABLE WHILE SWITCHING POWER SUPPLIES

"On 4/9/2012, starting at 0102 EDT, the 'A' and 'C' Emergency Diesel Generators (EDG) were sequentially and briefly declared inoperable to switch their DC control power back to their normal supplies. Switching power to the normal supply is required by Unit 2 technical specification 3.8.4 following maintenance work on the U1 power supplies. Previously, at 18:35 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 or 'C' EDG inoperable, neither Control Structure Chiller would 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 50.72(b)(3)(v)(D) as an 8 hour notification.

"Switching the power supplies was a planned evolution. The duration of the loss of safety function was a total of eight minutes. As a mitigating action, operators were continuously available with communication to the control room. The associated diesel generator could have been returned to an operable condition promptly if required.

"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 licensee notified the NRC Resident Inspector.

***RETRACTION FROM RON FRY TO S. SANDIN ON 6/7/12 AT 0205 EDT***

The licensee is retracting this report based on the following:

"On April 9, 2012, Susquehanna reported that the 'A' and 'C' Emergency Diesel Generators (EDGs) were sequentially and briefly declared inoperable to switch their DC control power back to their normal supplies while the 'B' Control Structure Chiller was inoperable. The basis for the 8 hour notification, which was reported under Reporting Requirement 50.72(b)(3)(v)(D), was the conclusion that neither Control Structure Chiller would be available to perform its design function on a loss of offsite power.

"The reporting guidance in NUREG-1022, Revision 2 identifies events or conditions that are generally not reportable in accordance with 50.72(b)(3)(v). One of the identified conditions is 'removal of a system or part of a system from service as part of a planned evolution for maintenance or surveillance testing when done in accordance with an approved procedure and the plant's TS (unless a condition is discovered that could have prevented the system from performing its function).' After further review, Susquehanna has determined that an ENS report was not required for this event since the EDGs and the associated 'A' Chiller were removed from service as part of a planned evolution in accordance with approved procedures and the plant Technical Specifications and no condition was discovered that could have prevented the EDGs and associated 'A' chiller from performing their function.

"Based on the above information, this ENS report is retracted."

The licensee informed the NRC Resident Inspector. Notified R1DO(Cahill).

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!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 47844
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: ALEX MCLELLAN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 04/17/2012
Notification Time: 21:02 [ET]
Event Date: 04/17/2012
Event Time: 15:40 [EDT]
Last Update Date: 06/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(C) - POT UNCNTRL RAD REL
Person (Organization):
JUDY JOUSTRA (R1DO)

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

UNIT 2 SECONDARY CONTAINMENT AFFECTED BY VIOLATION OF UNIT 1 SECONDARY CONTAINMENT INTEGRITY DURING OUTAGE

"At 1540 (EDT) on 4/17/12, with Unit 1 in mode 5 and Unit 2 in mode 1, the Work Control Center was notified that the U1 #2 Main Stop Valve (MSV) was disassembled. The U1 #2 MSV was required to be intact to maintain Unit 1 Secondary Containment. Ongoing work on the D Main Steam Line Outboard Valve created a pathway that violated Unit 1 secondary containment integrity. Unit 1 Secondary Containment is required to be operable for Unit 2 while Unit 1 Zone 1 is aligned to the Recirculation Plenum. Unit 1 Zone 1 was isolated from the recirculation plenum and Unit 2 Secondary Containment was restored at 1643 (EDT) on 4/17/12. Unit 2 Secondary Containment differential pressures were maintained throughout the event.

"This is considered a loss of an entire safety function and requires an 8 hour report per 10CFR50.72(b)(3)(v)(C)."

The licensee is still investigating the cause but it appears to be associated with recent administrative changes to the Reactor Vessel draining definition and work process procedures.

The licensee has notified the NRC Resident Inspector.

*** RETRACTION FROM RON FRY TO S. SANDIN ON 6/7/12 AT 0205 EDT ***

The licensee is retracting this report based on the following:

"On April 17, 2012, work on the Unit 1 'D' Main Steam Line Outboard Valve with the Unit 1 #2 Main Stop Valve disassembled created a pathway that violated Unit 1 secondary containment integrity. Since Unit 1 Secondary Containment is required to be operable for Unit 2 while Unit 1 Zone 1 would be aligned to the Recirculation Plenum in the event of a secondary containment isolation signal, the condition impacted Unit 2 Secondary Containment. Susquehanna considered the impact a loss of safety function and reported the impact in accordance with 10CFR50.72(b)(3)(v)(C).

"Following the ENS report, Susquehanna analyzed the impact of the opening. Calculations were performed that show secondary containment would have maintained the dose consequences to the public and control room operators within regulatory limits (10 CFR 50.67) assuming a Unit 2 design basis accident (Unit 1 was in a refueling outage at the time of the condition).

"Based on the above information, Susquehanna has determined that there was no loss of safety function and this ENS report is retracted."

The licensee informed the NRC Resident Inspector. Notified R1DO(Cahill).

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Agreement State Event Number: 47980
Rep Org: KENTUCKY DEPT OF RADIATION CONTROL
Licensee: OWENSBORO MEDICAL HEALTH SYSTEM
Region: 1
City: OWENSBORO State: KY
County:
License #: 202-161-26
Agreement: Y
Docket:
NRC Notified By: MICHELE GREENWELL
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/31/2012
Notification Time: 15:20 [ET]
Event Date: 06/04/2009
Event Time: [CDT]
Last Update Date: 06/05/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE ()

Event Text

AGREEMENT STATE REPORT - THREE MEDICAL EVENTS DISCOVERED DURING AN INSPECTION

The following report was received via e-mail:

"During a routine inspection, three unreported [prostate brachytherapy] medical events were identified.

"Case One:
Implant Date: 6/4/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 69.71%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 69

"Case Two:
Implant Date: 6/19/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 62.77%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 80

"Case Three:
Implant Date: 10/29/2009
Prescribed dose: 145Gy to the prostate
Post implant CT dosimetry: V100 (the volume of the prostate receiving 100% of the prescribed dose) totaled 65.34%
Source: I-125 encapsulated seeds
Vendor: IsoAid
Model Number: IAI-125A
Activity per seed: 0.330 mCi
Number of seeds implanted: 84

* * * UPDATE FROM CURT PENDERGRASS TO HOWIE CROUCH VIA EMAIL ON 6/5/12 AT 1018 EDT * * *

"D90 is defined as minimum dose received by 90% of CT-defined prostate volume

Case 1 D90 = 72.80% of 145Gy
Case 2 D90 = 58.86% of 145Gy
Case 3 D90 = 54.00% of 145Gy"

Notified R1DO (Cahill) and FSME Events via email.

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: 47982
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: SAMUEL STRAPPING SYSTEMS
Region: 1
City: FORT MILL State: SC
County:
License #: GL-0096
Agreement: Y
Docket:
NRC Notified By: LELAND CAVE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/31/2012
Notification Time: 15:37 [ET]
Event Date: 04/17/2012
Event Time: [EDT]
Last Update Date: 05/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE ()

Event Text

AGREEMENT STATE REPORT - GAUGE SHUTTER FAILED IN THE OPEN POSITION

The following report was received via fax:

"On May 31, 2012 at 1530 hrs [EDT], the SC Department of Health and Environmental Control was notified by phone that during a routine shutter check on April 17, 2012, an Automation and Control Technology (ACT) Model TG-7 gauging device containing 100 mCi of Sr-90, had a shutter mechanism that was harder to operate than normal. An ACT Model TG-7 technician was evaluating the operation of the shutter when it failed and was unable to be moved into the closed position. The ACT technician was able to replace the shutter assembly and switch on April 19, 2012. A survey, as well as a shutter check was performed to insure proper function. A report was sent from ACT to Samuel Strapping Systems on April 30, 2012."

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Agreement State Event Number: 47983
Rep Org: NC DIV OF RADIATION PROTECTION
Licensee: CAROLINA EAST MEDICAL CENTER
Region: 1
City: NEW BERN State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: RANDY CROWE
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 05/31/2012
Notification Time: 18:18 [ET]
Event Date: 05/29/2012
Event Time: [EDT]
Last Update Date: 05/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
FSME EVENTS RESOURCE ()

Event Text

AGREEMENT STATE REPORT - PROSTATE SEED MEDICAL EVENT

The following report was received via fax:

"Patient underwent Iodine 125 surgical prostate seed implants (total dose 145 Gy). Initial post operative X-ray film revealed complete seed count. Day zero computed tomography revealed all seeds inferior to true base and resulted in placement in the penile bulb vs. the prostate gland. There were no instrument malfunctions to include the ultrasound. Urologist notified and in-turn patient was immediately notified. Risk to urethra was discussed. Further investigation to occur from NC RPS [North Carolina Radiation Protection Section] Inspectors on Tuesday, June 12, 2012 awaiting the return of the authorized user/physician."

North Carolina incident: 12-37

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: 48000
Facility: DAVIS BESSE
Region: 3 State: OH
Unit: [1] [ ] [ ]
RX Type: [1] B&W-R-LP
NRC Notified By: ERIC HORVATH
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/07/2012
Notification Time: 02:39 [ET]
Event Date: 06/06/2012
Event Time: 19:56 [EDT]
Last Update Date: 06/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
DAVE PASSEHL (R3DO)

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

Event Text

DEGRADED CONDITION DUE TO DISCOVERY OF PRESSURE BOUNDARY LEAKAGE

"On June 6, 2012, at 1956 EDT, with the Unit shutdown for refueling, leakage was identified from a 3/4-inch weld during Reactor Coolant System (RCS) walkdown inspections. The leakage amount was approximately 0.1 gpm pinhole spray.

"During the performance of MODE 3 engineering walkdown inspections in accordance with procedure DB-PF-03010 (ASME Section III, Class 1 and 2), with the RCS at Normal Operating Temperature and Pressure, a pressure boundary leak was identified on the Reactor Coolant Pump (RCP) 1-2 1st seal cavity vent line upstream weld of 3/4 inch small bore pipe socketweld at a 90 degree elbow between the RCP pump and valve RC-407 (1st Seal Cavity Vent Isolation). The plant was in MODE 3 at Normal Operating Pressure and Normal Operating Temperature (NOP/NOT) for the inspections.

"The plant entered Technical Specification (TS) Limiting Condition for Operation (LCO) 3.4.13, 'RCS Operational Leakage,' Condition B and procedure DB-OP-02522. 'Small RCS Leaks,' abnormal operating procedure. Plant cooldown to comply with LCO 3.4.13, Condition B, Required Action B.2 is in progress. The cause and resolution are under evaluation.

"This event is reportable within 8 hours under 10CFR50.72(b)(3)(ii)(A).

"The NRC Resident Inspector has been notified. This condition has been documented in the Davis-Besse Corrective Action program as Condition Report 2012-09381."

The plant is required to be in MODE 5 within 36 hours.

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Power Reactor Event Number: 48001
Facility: LIMERICK
Region: 1 State: PA
Unit: [1] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: MARK ARNOSKY
HQ OPS Officer: DONG HWA PARK
Notification Date: 06/07/2012
Notification Time: 09:47 [ET]
Event Date: 06/07/2012
Event Time: 09:47 [EDT]
Last Update Date: 06/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)

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

TECHNICAL SUPPORT CENTER VENTILATION SYSTEM MAINTENANCE

"This ENS is being issued in advance of a planned activity. Today, 6/7/12, the (TSC) Technical Support Center Emergency Ventilation system will be removed from service to support preventive maintenance activities. The emergency ventilation system will not be available and cannot be restored within the time period required to staff and activate the Emergency Response Organization (ERO). The work will complete today, 6/7/12.

"If an emergency is declared and TSC ERO activation is required, the TSC will be staffed and activated unless the TSC becomes uninhabitable due to ambient temperatures, radiological or other conditions. If relocation of the TSC staff becomes necessary, the Station Emergency Director will relocate the staff to an alternate TSC location."

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48002
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL QUITTER
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/07/2012
Notification Time: 11:56 [ET]
Event Date: 06/07/2012
Event Time: 01:29 [PDT]
Last Update Date: 06/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
HEATHER GEPFORD (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

BOTH TRAINS OF LOW TEMPERATURE OVERPRESSURE SYSTEM INOPERABLE

"On June 7, 2012, at 0129 PDT, both trains of the low temperature overpressure (LTOP) system were rendered inoperable when the vital 120 VAC panel PY-13 was de-energized due to a human performance error. DCPP Unit 1 was in Mode 5, reactor coolant system loops not filled. Technicians were troubleshooting an existing de-energized vital 120 VAC panel PY-14 that had resulted from the supply breaker tripping open. The technician incorrectly opened the supply breaker to panel PY-13 instead of PY-14. With PY-14 de-energized, one train of LTOP was inoperable due to loss of signal from Reactor Coolant System (RCS) wide range pressure transmitter PT-405A. With PY-13 de-energized, the second train of LTOP was rendered inoperable due to loss of signal from RCS wide range pressure transmitter PT-403A. Operations immediately recognized the error and had the technician reclose the PY-13 supply breaker, thereby re-energizing panel PY-13, returning one train of LTOP back to its operable condition.

"Plant personnel notified the NRC Resident Inspector."

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Part 21 Event Number: 48004
Rep Org: FLOWSERVE
Licensee: FLOWSERVE
Region: 1
City: RALEIGH State: NC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: ROBERT D BARRY
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/07/2012
Notification Time: 14:19 [ET]
Event Date: 05/25/2012
Event Time: [EDT]
Last Update Date: 06/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
MALCOLM WIDMANN (R2DO)
DAVE PASSEHL (R3DO)
HEATHER GEPFORD (R4DO)
PART 21 GRP BY EMAIL ()

Event Text

PART 21 REPORT - PUBLISHED FLOW COEFFICIENTS FOR PILOT OPERATED RELIEF VALVES GREATER THAN ACTUAL

"This is to notify the US Nuclear Regulatory Commission, in accordance with the provisions of 10CFR-Part 21 of a potential deviation identified by Flowserve Corporation.

"On May 25, 2012, Flowserve Corporation notified Exelon - Byron and Braidwood Nuclear Power Stations of the results of a Steam flow test performed by Wyle Labs to confirm steam flow capacity against that specified for WKM PORVs. A refurbished size 6 class 900 WKM model 70-19-9 angle pattern control valve with 4" linear trim had been tested to determine its maximum steam flow capacity. The maximum steam flow was approximately 74% of the anticipated flow rate based on the original published WKM rated Cv for the valve.

"Background and Discussion: As part of their power up rate project, Exelon Braidwood Station procured larger 4" linear valve trim from Flowserve, Raleigh for their steam generator PORVs to increase the valve's steam flow capacity. The original valves were supplied by ACF Industries, WKM Valve Division in the mid to late 1970's with 3" linear trim. The designs for the WKM PORV valves were subsequently acquired by Flowserve. The larger trim was installed in a site spare PORV and tested for steam flow capacity.

"CFD analysis performed by Flowserve on the tested valve with the 4" trim, determined a Cv value that would yield steam flows similar to the test results. Analysis of the valve with the original 3" trim produced similarly reduced Cv values.

"Based on this testing and subsequent CFD analysis it appears that the originally published WKM rated Cv values for WKM angle control valve model 70-19-9 for sizes greater than size 2 are higher than actual values. The actual Cv's are believed to be 65% to 75% of the original WKM ratings.

"Conclusion: Based on the above, the Nuclear Industry needs to be notified concerning this deviation so that an evaluation may be performed to determine if this constitutes a defect that could create a substantial safety hazard.

"Although Flowserve subsequently acquired the rights to the WKM PORV designs, it does not have the historic sales records from ACF industries (WKM Valve Division). The total number of WKM valves potentially affected and their installed locations are not known."

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Power Reactor Event Number: 48005
Facility: COLUMBIA GENERATING STATION
Region: 4 State: WA
Unit: [2] [ ] [ ]
RX Type: [2] GE-5
NRC Notified By: MOT HEDGES
HQ OPS Officer: DONALD NORWOOD
Notification Date: 06/07/2012
Notification Time: 19:16 [ET]
Event Date: 09/17/2011
Event Time: 12:00 [PDT]
Last Update Date: 06/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
HEATHER GEPFORD (R4DO)

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

MAJOR LOSS OF EMERGENCY ASSESSMENT CAPABILITY DUE TO DEGRADED DOSE PROJECTION

"On September 17, 2011, a root cause analysis identified that errors in the dose projection software gain factor associated with the high range stack monitor were introduced in 2000 and had the potential to produce inaccurate dose projection results. The resulting condition could have impacted the ability to accurately assess ongoing releases and determine appropriate protective measures for the public. The gain factors were corrected in October 2011 and dose projection capabilities have been restored.

"This condition was not originally recognized as being reportable in accordance with 10 CFR 50.72(b)(3)(xiii) due to the limited nature of the impact to a small portion of the radiological effluent EALs, however, it has been recently determined to be reportable. This late identification of reportability has been entered into our corrective action program."

The licensee will notify the NRC Resident Inspector.

Page Last Reviewed/Updated Friday, June 08, 2012
Friday, June 08, 2012