United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for July 23, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/20/2012 - 07/23/2012

** EVENT NUMBERS **


48098 48122 48123 48124 48125

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Agreement State Event Number: 48098
Rep Org: OHIO BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITIES HOSPITAL OF CLEVELAND
Region: 3
City: CLEVELAND State: OH
County:
License #: 02110180007
Agreement: Y
Docket:
NRC Notified By: KARL VON AHN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 07/12/2012
Notification Time: 13:10 [ET]
Event Date: 07/10/2012
Event Time: 17:00 [EDT]
Last Update Date: 07/12/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
ERIC DUNCAN (R3DO)
FSME RESOURCES (EMAI)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE DURING A YTTRIUM-90 THERASPHERE TREATMENT

The following information was provided by the Ohio Bureau of Radiation Protection via e-mail:

"A written directive was given for a patient to receive 115 mCi of Y-90 TheraSpheres microspheres.

"During the delivery of the microspheres, stasis occurred before the full quantity of the written directive delivered. The licensee did not expect to reach stasis, and will be sending the delivery system to the manufacturer after the remaining Y-90 decays to verify that there was not an equipment malfunction. The licensee calculates that the patient received 68.6 mCi, which is only 60% of the written directive (a 40% underdose). The written directive did not indicate include the phrase 'or until stasis'.

"The licensee has notified the attending physician. The licensee will be contacting the patient's physician prior to contacting the patient.

"The licensee states that there are no adverse effects to the patient. No corrective action is planned at this time.

"Event Discovered: July 11, 2012 at 11:00 am
Event Date: July 10, 2012 at 5:00 pm

"Reporting criteria - medical event
OAC 3701:1-58-101(a)(1)(a)
10 CFR 35.3045(a)(1)(i) "

Ohio Event Report #2012-017

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: 48122
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [ ] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: STEVER SCHMIDT
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/20/2012
Notification Time: 16:55 [ET]
Event Date: 07/20/2012
Event Time: 14:00 [CDT]
Last Update Date: 07/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
LAURA KOZAK (R3DO)

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 EMERGENCY DIESEL GENERATORS INOPERABLE DUE TO MISSING FLOOD CONTROL BARRIER SEAL

"D5 and D6 Diesel Generators (DG) were declared inoperable at 1400 CDT due to a missing internal flood control barrier seal. The missing flood control barrier seal is required to be installed with Unit 2 in Modes 1, 2, 3, and 4 when the MSIV's are open.

"LCO 3.8.1 Condition B was entered for both DGs and LCO 3.8.1 Condition E was entered for two DGs inoperable on the same unit. The DGs could start and run if required at the time of entry.

"This condition is reportable per 10CFR50.72(b)(3)(v) as an event or condition that could have prevented the fulfillment of a safety function.

"At 1505 CDT the missing internal flood barrier seal was verified in place restoring the safety function. LCO 3.8.1 Condition B and E were exited.

"The NRC Resident Inspector has been informed."

At this time, it is not known how long the seals had been missing. An investigation is on-going.

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Power Reactor Event Number: 48123
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: MARK EGHIGIAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/20/2012
Notification Time: 22:27 [ET]
Event Date: 07/20/2012
Event Time: 22:30 [EDT]
Last Update Date: 07/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
LAURA KOZAK (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

ANTICIPATORY LOSS OF SPDS AND ERDS DUE TO POSSIBLE LOSS OF INTEGRATED PLANT COMPUTER SYSTEM DURING TROUBLESHOOTING

"Beginning July 20, 2012, at approximately 2230, troubleshooting of MUX A components and fiber optic cables on the Fermi 2 Integrated Plant Computer System (IPCS) will be performed. A loss of IPCS during the troubleshooting is possible.

"The Safety Parameters Display System (SPDS) and Emergency Response Data System (ERDS) reside on the IPCS platform and will be out of service if IPCS is lost. These systems would be unavailable to the Control Room and all other Emergency Response Facilities (ERFs). During this time dose assessment capability would only be available in the manual data input mode. The majority of the Control Room indications will remain available to the plant staff, and would be used for emergency response, if needed. Information would be communicated to the NRC using other available communication systems as needed. A follow-up notification will be submitted when the IPCS troubleshooting is complete.

"This notification is being made per the requirements of 8 Hour Non-Emergency Notification 10CFR50.72(b)(3)(xiii), any event that results in a major loss of emergency assessment capability."

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 48124
Facility: CALVERT CLIFFS
Region: 1 State: MD
Unit: [1] [ ] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: CHARLES MORGAN
HQ OPS Officer: DONALD NORWOOD
Notification Date: 07/21/2012
Notification Time: 13:10 [ET]
Event Date: 07/21/2012
Event Time: 12:10 [EDT]
Last Update Date: 07/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
ANTHONY DIMITRIADIS (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

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN DUE TO RCS PRESSURE BOUNDARY INSTRUMENT LINE LEAKAGE

"[Calvert Cliffs Nuclear Power Plant] CCNPP U1 identified RCS Pressure Boundary Leakage from the instrument line to 1-PDT-123A, 11A reactor coolant pump differential pressure transmitter. Technical Specification 3.4.13, Action B was entered and requires that the Unit be placed in Mode 3 within 6 hours and Mode 5 within 36 hours. [The licensee has] initiated plant shutdown in accordance with this Technical Specification. Therefore, this is reportable under 10CFR50.72(b)(2)(i) Plant Shutdown Required by Technical Specifications. This is also reportable under 50.72(B)(3)(ii)(A) as a material defect in the primary coolant system that cannot be found acceptable under ASME Section XI, IWB-3600 or ASME Section XI, Table IWB-3410-1."

The leak is from an instrument line which monitors reactor coolant pump differential pressure. It is for monitoring purposes only. The leak rate is currently about .08 gpm. The licensee has begun power reduction of the unit and is currently at approximately 73% rated thermal power. The recovery plan is to complete the unit shutdown and then enter containment and repair the leak.

The leak is believed to be coming from the same instrument line that was reported to be leaking on July 17, 2012 (see EN #48116). At that time, power was reduced to approximately 10% and a containment entry was made. At that time it was believed that the leak had been isolated and full power operations were resumed. Based on containment sump pump run times and another containment entry, it was determined that the leak apparently had not been isolated.

The licensee notified the NRC Resident Inspector.

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Power Reactor Event Number: 48125
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: ROBERT SALES
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/23/2012
Notification Time: 04:24 [ET]
Event Date: 07/23/2012
Event Time: 03:29 [EDT]
Last Update Date: 07/23/2012
Emergency Class: UNUSUAL EVENT
10 CFR Section:
50.72(a) (1) (i) - EMERGENCY DECLARED
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
Person (Organization):
ANTHONY DIMITRIADIS (R1DO)
HO NIEH (NRR)
WILLIAM GOTT (IRD)
BILL DEAN (R1RA)
BRUCE BOGER (NRR)
HASSEL (DHS)
GUERRA (FEMA)
GAMBINO (NICC)

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

Event Text

UNUSUAL EVENT DUE TO LOSS OF OFFSITE POWER

"At 0329 EDT, Oyster Creek experienced a loss of offsite power and a full reactor scram. All safety systems functioned as required. Unusual Event due to loss of offsite AC power to 4160V buses 1C and 1D for greater than 15 minutes. The cause of the loss of offsite power is currently under investigation by JCP&L."

At 0341 EDT, Oyster Creek declared an Unusual Event based on a loss of offsite power for greater than 15 minutes. As a result of the loss of offsite power, the unit automatically scrammed from 100% with all control rods fully inserting and all safety systems functioning as required. Both Emergency Diesel Generators automatically started and are carrying loads on the safety buses. The unit is stable in Hot Shutdown with decay heat removal via the Isolation Condenser.

The licensee notify the State and local agency, as well as, the NRC Resident Inspector. The licensee will be making a press release.

Page Last Reviewed/Updated Monday, July 23, 2012
Monday, July 23, 2012