United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for August 29, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
08/28/2012 - 08/29/2012

** EVENT NUMBERS **


48063 48207 48208 48216 48218 48228 48238 48239 48245 48246

To top of page
!!!!! THIS EVENT HAS BEEN RETRACTED. THIS EVENT HAS BEEN RETRACTED !!!!!
Power Reactor Event Number: 48063
Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [ ] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: DONG HWA PARK
Notification Date: 07/02/2012
Notification Time: 18:42 [ET]
Event Date: 07/02/2012
Event Time: 15:51 [CDT]
Last Update Date: 08/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(v)(A) - POT UNABLE TO SAFE SD
Person (Organization):
ROBERT DALEY (R3DO)

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

BOTH DIESEL GENERATORS DECLARED INOPERABLE

"D1 and D2 Diesel Generators (DG) were declared inoperable at 1551 CDT due to exceeding the maximum outside air temperature limit of 97 degree F. This limit was based on heatup analysis for a HELB [High Energy Line Break] in the turbine building. The temperature is measured using the 15 min average of air temperature at the 10 meter meteorological tower, which approximates the intake height for room ventilation.

"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 10 CFR 50.72(b)(3)(v) as an event or condition that could have prevented the fulfillment of a safety function.

"During review of the analysis, two pressure switches on D2 and one on D1 were identified as being limiting and a modification was approved to replace them. Upon replacement, the limiting outside temperature would increase to 100.5 degree F. Replacement of components had been completed for D2 diesel generator prior to LCO entry; however, the temperature limit of 100.5 degree F had not yet been approved.

"Shortly after D1 was declared inoperable, it was isolated to complete the component replacement which is expected to take less than four hours. D1 will return to operable once the component replacement and PMT is completed.

"At 1630 [CDT] D2 was declared operable based on approval of a revised operability recommendation that raised the outside temperature limit to 100.5 degree F.

"Outside air temperature peaked at 97.1 degree F and is slowly decreasing."

The licensee has notified the NRC Resident Inspector.

* * * RETRACTION FROM GENE DAMMANN TO DONALD NORWOOD AT 1555 EDT ON 8/28/12 * * *

"Event Notification 48063 reported that D1 and D2 Diesel Generators (DG) were inoperable due to exceeding the maximum outside air temperature limit of 97 degree F.

"An additional approved evaluation determined that the D2 lube oil pressure switches were replaced prior to exceeding the outside ambient air temperature limit. The new lube oil pressure switches have a higher temperature rating that supports a higher outside ambient air temperature, therefore, D2 was able to fulfill its safety function and Event Notification 48063 is retracted.

"The NRC Resident Inspector has been informed."

Notified R3DO (Cameron).

To top of page
Agreement State Event Number: 48207
Rep Org: OR DEPT OF HEALTH RAD PROTECTION
Licensee: OREGON HEALTH & SCIENCE UNIVERSITY
Region: 4
City: PORTLAND State: OR
County:
License #: ORE-90013
Agreement: Y
Docket: 12-0677
NRC Notified By: KEVIN SIEBERT
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/20/2012
Notification Time: 13:26 [ET]
Event Date: 08/13/2012
Event Time: [PDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
FSME_EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - MEDICAL EVENT INVOLVING DELIVERY OF UNDERDOSAGE

The following information was received from the State of Oregon via email:

"[The licensee reported] a misadministration on Monday, August 13, 2012, during a treatment with [Y-90] TheraSpheres. The misadministration was due to a malfunction of the syringe plunger of the delivery device, and is the first time that this problem has occurred at Oregon Health & Science University.

"This was a two-vial treatment, and the malfunction occurred with the first delivery set. (The activity from the second vial, and with a new delivery set, was administered with no difficulty. Delivery sets are single-use.). The nurse who was setting up the system, and who routinely sets up the systems, noticed a stiffness when she was snapping the plunger into position through the vial septum. She was not able to retract the needles (the plunger is designed not to be removable), and it appeared to be placed properly.

"The physician was informed of the 'stickiness'. The patient's catheter was correctly hooked up to the delivery device, and the catheter in the patient was in the desired position. As soon as the administration was started, blood backed up into the catheter, which was unusual. Normal attempts to administer the activity by pushing saline into the vial resulted in fluid running into the over-pressure vial. The treating physician ended the attempt to deliver the activity, and the system was removed in the normal way by placing the used items in the waste container.

"The second delivery set and the second dose vial were placed in position, the patient catheter hooked up, and the delivery of the activity went smoothly.

"The patient was notified of the problem and of the possibility of a retreat. The Oregon Department of Health Radiation Protection are waiting for the Nordion technical adviser to call mid-day today.

"The Y-90 TheraSphere treatment consisted of:

Vial 1 - Script 66 Gray, Administered 12 Gray, 81.8 % Error of 54 Gray
Vial 2 - Script 55 Gray, Administered 50.2 Gray, 8.7 % Error of 4.8 Gray
Treatment Total - Script 121 Gray, Administered 62.2 Gray, 48.5 % Error of 58.8 Gray"

Oregon Incident # - 12-0031

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.

To top of page
Agreement State Event Number: 48208
Rep Org: LOUISIANA RADIATION PROTECTION DIV
Licensee: QUALITY INSPECTION & TESTING, INC
Region: 4
City:  State: LA
County:
License #: LA-11238-L01
Agreement: Y
Docket:
NRC Notified By: JAMES PATE
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/20/2012
Notification Time: 14:52 [ET]
Event Date: 05/12/2012
Event Time: [CDT]
Last Update Date: 08/20/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
MICHAEL HAY (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POTENTIAL OVEREXPOSURE TO RADIOGRAPHER

The following information was provided by the State of Louisiana via facsimile:

"On approximately May 14, 2012, a radiographer was performing industrial radiography. He dropped his badge approximately 7 feet from the industrial radiography camera for one to two welds. On approximately May 12, 2012 he was performing Mag inspections and had left his dosimetry in his parked car. He noticed some industrial radiography crews performing work near his vehicle. His badge read 7028 DDE [Deep Dose Equivalent] and 6972 SDE [Shallow Dose Equivalent].

"He stated that his pocket ion chamber never went off scale. None of his crew members badges and pocket ion chambers showed any exposure during the time they worked together. Louisiana Department of Environmental Quality is sending an inspector to investigate the dosimetry over exposure."

LA Event Report ID No.: LA120003

To top of page
Agreement State Event Number: 48216
Rep Org: NH DEPT OF HEALTH & HUMAN SERVICES
Licensee: BED BATH AND BEYOND
Region: 1
City: CONCORD State: NH
County:
License #: GL
Agreement: Y
Docket:
NRC Notified By: TWILA KENNA
HQ OPS Officer: STEVE SANDIN
Notification Date: 08/21/2012
Notification Time: 09:23 [ET]
Event Date: 08/08/2012
Event Time: [EDT]
Last Update Date: 08/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1DO)
ANGELA MCINTOSH (FSME)
FSME RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT - IMPROPER DISPOSAL OF TRITIUM EXIT SIGNS

The following information was received from the State of New Hampshire:

"On August 8, 2012, a [Bed Bath and Beyond Vice President] called to report the loss of seventeen tritium exit signs. After taking the signs down, they were stored for Shaw Environmental to package and ship them for disposal. While being stored, they were mistakenly taken by another contractor as part of the waste from light bulb removal. This removal was viewed on videotape after Shaw Environmental reported that the box of signs was missing from the storage area.

"[The Bed Bath and Beyond VP] contacted RL Carriers (the removal contractor) to find out where they send the waste for disposal. The location was Waste Management in South Carolina. [The Bed Bath and Beyond VP] contacted Waste Management and was told that they had not received any exit signs but if they had, they would have sent them to Synergy Recycling in North Carolina. When contacted, Synergy Recycling stated that they had not received any exit signs.

"The serial numbers for the 17 Tritium Exit Signs that cannot be located are listed below. The Manufacturer is Safety Light, model SLK-60.

301364 - 301367
301370 - 301376
301381
303792
303794 - 303797"

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

To top of page
Agreement State Event Number: 48218
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 08/21/2012
Notification Time: 16:27 [ET]
Event Date: 08/21/2012
Event Time: [EDT]
Last Update Date: 08/21/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
WILLIAM COOK (R1DO)
FSME_EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE - RADIATION TREATMENT OVERDOSE RESULTING FROM A POTENTIAL GENERIC ISSUE

The following information was provided by the State of Pennsylvania via facsimile:

"On Monday, August 20, 2012, the licensee informed the Pennsylvania Department of Environmental Protection's Southcentral Regional Office of a medical event which occurred the same day. It is reportable within 24-hours under 10 CFR 35.3045(a)(1)(iii).

"During the first fraction of radiation therapy treatment, using a Nucletron Corporation microSelectron HDR (High Dose Rate) Model 106.990 remote afterloader, the unit's treatment planning software malfunctioned, resulting in an overdose to the patient of approximately 76.5%. Facility staff also failed to complete a required worksheet which may have alerted the Authorized User to the dosage difference prior to treatment. A total dose of 600 cGy (rad) was delivered instead of the prescribed 340 cGy (rad). The patient was notified on the same day, while the referring physician was notified the following day. The treating physician anticipates no effect to the patient, however, dose reconstruction is currently in progress. We believe this incident also qualifies the event as an Abnormal Occurrence.

"Cause of the event is equipment malfunction and human error.

"Licensee is contacting a service provider for the HDR unit to investigate the incident, and if needed, repair the equipment. The Pennsylvania Department of Environmental Protection will be evaluating possible generic implications and plans to do a reactive inspection as soon as possible."

PA Event Report No: PA120025

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.

To top of page
Fuel Cycle Facility Event Number: 48228
Facility: NUCLEAR FUEL SERVICES INC.
RX Type: URANIUM FUEL FABRICATION
Comments: HEU CONVERSION & SCRAP RECOVERY
                   NAVAL REACTOR FUEL CYCLE
                   LEU SCRAP RECOVERY
Region: 2
City: ERWIN State: TN
County: UNICOI
License #: SNM-124
Agreement: Y
Docket: 07000143
NRC Notified By: RANDY SHACKELFORD
HQ OPS Officer: CHARLES TEAL
Notification Date: 08/24/2012
Notification Time: 14:20 [ET]
Event Date: 08/23/2012
Event Time: 19:45 [EDT]
Last Update Date: 08/24/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
74.57 - ALARM RESOLUTION
Person (Organization):
ROBERT HAAG (R2DO)
GORDON BJORKMAN (NMSS)
FUELS OUO GROUP (EMAI)

Event Text

MATERIAL CONTROL AND ACCOUNTABILITY ALARM RESOLUTION

"10 CFR 74.57 (f)(2) requires notification within 24 hours that a Material Control & Accountability (MC&A) alarm resolution procedure has been initiated. In the Solvent Extraction Area of Building 333, the input minus output value exceeded the MC&A limit. Because the alarm investigation procedure has been initiated, this notification is being made. There was no material loss and the issue was resolved on 8/24/2012.

"MC&A process monitoring tests for material balance were run as specified by applicable procedures and requirements. Based on the test results for Building 333 solvent extraction area, the test limit was exceeded. The investigation was completed and the alarm was resolved on 8/24/2012.

"There was no actual or potential safety consequences to workers, the public, or the environment."

The NRC Resident Inspector has been informed.

To top of page
Power Reactor Event Number: 48238
Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: MICHAEL BOTTORFF
HQ OPS Officer: PETE SNYDER
Notification Date: 08/28/2012
Notification Time: 06:13 [ET]
Event Date: 08/28/2012
Event Time: 03:32 [EDT]
Last Update Date: 08/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
Person (Organization):
ROBERT HAAG (R2DO)

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

Event Text

AUTOMATIC REACTOR TRIP FOLLOWING FAILURE OF A FEEDWATER REGULATING VALVE

"On August 28, 2012, Watts Bar Nuclear Plant Unit 1 reactor automatically tripped due to low level in steam generator (SG) #2. The low level resulted when the Main Feedwater Control Valve for SG#2 (1-FCV-3-48) failed closed. This is being reported under 10CFR 50.72 (b)(2) (iv) (B).

"Concurrent with the reactor trip the Auxiliary Feedwater system actuated as designed. This is being reported under 10CFR 50.72(b)(3) (iv)(A).

"All Control and Shutdown rods fully inserted.

"All safety systems responded as designed. The unit is currently stable in Mode 3.

"The NRC Senior Resident has been notified."

Decay heat is being removed to the main condenser via condenser steam dumps. The plant is in its normal shutdown electrical lineup. No steam safety or relief valves lifted during the event.

To top of page
Power Reactor Event Number: 48239
Facility: SURRY
Region: 2 State: VA
Unit: [ ] [2] [ ]
RX Type: [1] W-3-LP,[2] W-3-LP
NRC Notified By: TIM KEATING
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 08/28/2012
Notification Time: 10:11 [ET]
Event Date: 08/27/2012
Event Time: 09:00 [EDT]
Last Update Date: 08/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
OTHER UNSPEC REQMNT
Person (Organization):
ROBERT HAAG (R2DO)
MARK KING (NRR)
WILLIAM GOTT (IRD)
VICTOR McCREE (RA)
ERIC LEEDS (NRR)

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

DISCOVERY OF AFTER-THE-FACT EMERGENCY CONDITION - ALERT - HIGH CO2 CONCENTRATION IN A SAFE SHUTDOWN AREA

"At 0927 EDT on 08/28/2012, it was identified that access to a table H-1 Safe Shutdown Area had been prohibited and that an ALERT had not been declared as required by Surry EPIP-1.01, EAL HA 3.1. At 0900 EDT on 08/27/2012, Electrical Maintenance was performing a surveillance on the Unit 2 Cable Vault and Cable Tunnel Low Pressure CO2 System. A high CO2 level was observed using portable gas detection equipment and access to the space was prohibited for a period of approximately 20 minutes. This report is being made in compliance of VPAP-2802, section 6.3.3(h), which states that a one hour report is required if an Emergency Action Level (EAL) is exceeded, the basis for the emergency class no longer exists at the time of discovery, and no other reasons exist for an emergency declaration."

The licensee will notify the NRC Resident Inspector and Virginia Emergency Management Agency.

To top of page
Power Reactor Event Number: 48245
Facility: CALLAWAY
Region: 4 State: MO
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: TIM HOLLAND
HQ OPS Officer: HOWIE CROUCH
Notification Date: 08/28/2012
Notification Time: 18:51 [ET]
Event Date: 08/28/2012
Event Time: 15:00 [CDT]
Last Update Date: 08/28/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
DAVID PROULX (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

Event Text

TECHNICAL SUPPORT CENTER DETERMINED TO BE NON-FUNCTIONAL DUE TO LOW RECIRC FLOW

"At 1500 CDT on Tuesday, August 28, the Callaway Plant Technical Support Center (TSC) was declared non-functional due to ventilation recirculation flow rate outside of normal limits.

"Efforts are underway to restore TSC ventilation recirculation flow rate to normal.

"If TSC activation is necessary during the period of TSC non-functionality, the Emergency Coordinator will evaluate the suitability of the facility for the specific conditions of the event.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to the unavailability of an emergency response facility.

"The NRC Resident Inspector has been notified"

To top of page
Power Reactor Event Number: 48246
Facility: DIABLO CANYON
Region: 4 State: CA
Unit: [1] [2] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DAN STERMER
HQ OPS Officer: JOHN KNOKE
Notification Date: 08/29/2012
Notification Time: 00:16 [ET]
Event Date: 08/28/2012
Event Time: 17:00 [PDT]
Last Update Date: 08/29/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(B) - UNANALYZED CONDITION
50.72(b)(3)(v)(D) - ACCIDENT MITIGATION
Person (Organization):
DAVID PROULX (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

MITIGATING ACTIONS IMPLEMENTED FOR INOPERABLE CONTROL ROOM ENVELOPE

"On August 28, 2012, 17:00 PDT, Pacific Gas and Electric Company (PG&E) identified additional release pathways that could affect the control room (CR) operator dose following a Large-Break Loss-of-Coolant Accident (LBLOCA). Consequently, PG&E declared the control room envelope (CRE) inoperable and is establishing mitigative actions in accordance with TS 3.7.10, Action B.1, 'Initiate action to implement mitigating actions' immediately, and Action B.2, 'Verify mitigating actions ensure CRE occupant exposures to radiological hazards will not exceed limits, and CRE occupants are protected from smoke and chemical hazards' within 24 hours.

"PG&E is establishing mitigative actions in accordance with TS 3.7.10 and RG 1.196. These mitigative actions are for operations control room personnel to administer potassium iodide and don self-contained breathing apparatus equipment in a timely fashion should a LBLOCA occur. They will be communicated and controlled by a standing order to the control room staff.

"PG&E previously established controls on other release pathways that offset the potential increases to the maximum predicted offsite dose due to the new release pathways. No increase in maximum predicted offsite dose is expected from the new release pathways.

"Diablo Canyon (DCPP) is making this 8-hour, non-emergency notification under 10 CFR 50.72(b)(3)(ii)(B) and 10 CFR 50.72(b)(3)(v)(D).

"Plant personnel notified the NRC Resident Inspector."

Page Last Reviewed/Updated Wednesday, August 29, 2012
Wednesday, August 29, 2012