United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for September 17, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
09/14/2012 - 09/17/2012

** EVENT NUMBERS **


48280 48281 48286 48305 48306 48309 48310 48311 48312

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Agreement State Event Number: 48280
Rep Org: MA RADIATION CONTROL PROGRAM
Licensee: BERKSHIRE MEDICAL CENTER
Region: 1
City: PITTSFIELD State: MA
County:
License #: SN-1439
Agreement: Y
Docket:
NRC Notified By: MICHAEL P WHALEN
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 09/06/2012
Notification Time: 11:17 [ET]
Event Date: 05/24/2012
Event Time: [EDT]
Last Update Date: 09/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)
FSME RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT - RECOVERED PACEMAKER

"A patient with a Pu-238 pacemaker died on 5/16/12 and was scheduled to be buried on 5/26/2012. Berkshire Medical Center (BMC) observed the obituary in the newspaper on 5/24/2012 and contacted funeral home to retrieve the pacemaker. The funeral home still possessed the pacemaker as it was extracted before the patient was cremated. On 5/24/2012, the BMC Radiation Safety Officer retrieved the pacemaker. Radiation measurements of the pacemaker were less than 1 mR/hr near the surface and not detectable above background at 1 meter. Leak tests were also not detectable above background.

"BMC registered the source with the DOE Off-Site Recovery Project (OSRP) to have it disposed."

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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Agreement State Event Number: 48281
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: STERIS ISOMEDIX SERVICES
Region: 1
City: SPARTANBURG State: SC
County:
License #: 267
Agreement: Y
Docket:
NRC Notified By: MARK L. WINDHAM
HQ OPS Officer: PETE SNYDER
Notification Date: 09/06/2012
Notification Time: 16:25 [ET]
Event Date: 09/06/2012
Event Time: 06:02 [EDT]
Last Update Date: 09/06/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - SOURCE RACK STUCK IN UNSHIELDED POSITION

The State of South Carolina submitted the following information via email:

"The SC Department of Health and Environmental Control [SCDHEC] was notified on Thursday, September 6, 2012, at 1500 EDT, that rack #2 failed to return to a shielded position at 0605 EDT due to a cleaning rag that was inadvertently wrapped around the source rack hoist cable. The RSO/Maintenance Manager for the facility stated that authorized personnel were able to clear the obstruction and return the rack to a shielded position at 0700 EDT. There were no personnel exposures and no equipment damage.

"This event is open and pending the licensee's investigation and report to the SCDHEC. Updates will be made through the national NMED system."

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Agreement State Event Number: 48286
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: UNIVERSITY OF PITTSBURGH
Region: 1
City: PITTSBURGH State: PA
County: ALLEGHENY
License #: PA-0190
Agreement: Y
Docket:
NRC Notified By: JOSEPH MELNIC
HQ OPS Officer: PETE SNYDER
Notification Date: 09/07/2012
Notification Time: 14:29 [ET]
Event Date: 09/06/2012
Event Time: [EDT]
Last Update Date: 09/07/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICHARD CONTE (R1DO)

Event Text

AGREEMENT STATE REPORT - YTTRIUM-90 MICROSPHERES ADMINISTERED TO THE WRONG TREATMENT SITE

"On September 6, 2012, the [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (PADEPBRP)] Central Office received notification via a phone call about this medical event.

"The patient received an administration of approximately 1.4 millicuries (mCi) of Y-90 microspheres to the wrong treatment site. The intended treatment was to administer approximately 24 mCi to the left lobe of the liver through three different arteries. During the administration of one of the split doses, the Interventional Radiologist (IR) incorrectly positioned the catheter in the right hepatic artery. A portion of the one split dose was administered to the right lobe of the liver before the IR realized that the catheter was not in the correct artery.

"Cause of the event: Human Error.

"Actions: Both the referring physician and the patient have been notified of the medical event. The [PADEPBRP] plans to do a reactive inspection."

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: 48305
Facility: POINT BEACH
Region: 3 State: WI
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: MARY SIPIORSKI
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/13/2012
Notification Time: 19:36 [ET]
Event Date: 09/13/2012
Event Time: 14:28 [CDT]
Last Update Date: 09/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
MICHAEL KUNOWSKI (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
2 N Y 100 Power Operation 100 Power Operation

Event Text

TECHNICAL SUPPORT CENTER NON-FUNCTIONAL DUE TO TSC VENTILATION EQUIPMENT ISSUE

"The Technical Support Center (TSC) at the Point Beach Nuclear Plant (PBNP) is non-functional as a result of conservatively securing an exhaust fan that exhibited an abnormal noise in the TSC Ventilation system. The fan is currently in service and being monitored as part of the troubleshooting, with maintenance repair plans being conducted in parallel.

"Functional alternate locations described in the emergency plan procedures for events resulting in radiological conditions affecting habitability will be used and are currently available. The Control Room or EOF will be selected as the alternate facility. If an emergency is declared requiring TSC activation during this period, the TSC will be staffed and activated using the procedure and functional facilities selected.

"This notification is being made in accordance with 10 CFR 50.72(b)(3)(xiii) due to the loss of an Emergency Response Facility (ERF). An update will be provided once the TSC ventilation system has been restored to normal operation."

The licensee has notified the NRC Resident Inspector.

* * * UPDATE FROM MARY SIPIORSKI TO CHARLES TEAL ON 9/14/12 AT 1942 EDT * * *

"At 1737 on 9/14/12, maintenance activities are complete on the TSC ventilation system. The TSC ventilation has been restored to normal operation and the TSC [has been] returned to fully functional."

The licensee has notified the NRC Resident Inspector. Notified R3DO (Kunowski).

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Power Reactor Event Number: 48306
Facility: SAINT LUCIE
Region: 2 State: FL
Unit: [1] [2] [ ]
RX Type: [1] CE,[2] CE
NRC Notified By: REESE KILIAN
HQ OPS Officer: BILL HUFFMAN
Notification Date: 09/14/2012
Notification Time: 11:20 [ET]
Event Date: 09/14/2012
Event Time: [EDT]
Last Update Date: 09/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
26.719 - FITNESS FOR DUTY
Person (Organization):
SCOTT SHAEFFER (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
2 N N 0 0

Event Text

FITNESS FOR DUTY - CONTRACT SUPERVISOR TESTED POSITIVE FOR ALCOHOL

A non-licensed contract employee supervisor had a confirmed positive for alcohol during a random fitness-for-duty test. The employee's access to the plant has been terminated. Contact the Headquarters Operations Officer for additional details.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48309
Facility: FERMI
Region: 3 State: MI
Unit: [2] [ ] [ ]
RX Type: [2] GE-4
NRC Notified By: BRETT JEBBIA
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2012
Notification Time: 19:27 [ET]
Event Date: 09/14/2012
Event Time: 16:03 [EDT]
Last Update Date: 09/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(A) - ECCS INJECTION
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
MICHAEL KUNOWSKI (R3DO)
DAVID SKEEN (NRR)
WILLIAM GOTT (IRD)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 A/R Y 68 Power Operation 0 Hot Shutdown

Event Text

AUTOMATIC REACTOR SCRAM DUE TO THE LOSS OF THE 120 KV SWITCHYARD

"At 1603 EDT, Fermi 2 automatically scrammed due to onsite loss of 120 kV switchyard. All control rods fully inserted. The lowest Reactor Water Level (RWL) reached was 98 inches. Division I diesels, EDG-11 and EDG-12, automatically started and loaded. HPCI and RCIC automatically started and restored RWL. RWL is currently being maintained in the normal level band with Condensate/Feed and Control Rod Drive (CRD) systems. No Safety Relief Valves (SRV) actuated. All isolations and actuations for RWL 3 and 2 occurred as expected. Investigation into loss of 120 kV switchyard continues.

"At the time of the scram, all Emergency Core Cooling (ECCS) and Emergency Diesel Generators (EDG) were operable with the exception of EDG-11 which was available vice operable due to ventilation work, and no other safety related equipment was out of service. This report is being made in accordance with 10CFR50.72(b)(2)(iv)(A), any event that results in ECCS discharge into the reactor coolant system as a result of a valid signal and 10CFR50.72(b)(2)(iv)(B), any event that results in actuation of the reactor protection system (RPS) when the reactor is critical."

EDG-11 and EDG-12 are performing all of their functions and providing power to the Division I AC buses. Temperatures are being monitored in the room containing EDG-11 and the room is not approaching any temperature limits. The MSIVs are open with decay heat being removed via steam to the main condenser using the bypass valves.

The licensee has notified the NRC Resident Inspector.

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Power Reactor Event Number: 48310
Facility: SEABROOK
Region: 1 State: NH
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP
NRC Notified By: SHAWN MILLER
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/14/2012
Notification Time: 22:05 [ET]
Event Date: 09/14/2012
Event Time: 20:25 [EDT]
Last Update Date: 09/14/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
1 A/R Y 85 Power Operation 0 Hot Standby

Event Text

AUTOMATIC REACTOR TRIP DUE TO LOW STEAM GENERATOR WATER LEVEL

"[At] 2025 [EDT] reactor tripped on 'C' Steam Generator Low Low Level due to feed water regulating valve failing closed due to a 7300 process cabinet card failure. Control Room entered E-0, Reactor Trip or Safety Injection, then transitioned to ES-0.1, Reactor Trip Response.

"Emergency Feedwater actuated due to the Low Low Steam Generator Level. All other plant equipment functioned as expected. Plant is being stabilized in mode 3.

"Emergency News Manager will update the states and local media.

"NRC Resident Inspector was notified at 2045 [EDT]."

The trip was uncomplicated and all rods fully inserted. Decay heat is being removed to the condenser via the turbine bypass valves. Electrical buses are powered by offsite power.

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Power Reactor Event Number: 48311
Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: HARRIS WELT
HQ OPS Officer: HOWIE CROUCH
Notification Date: 09/15/2012
Notification Time: 03:10 [ET]
Event Date: 09/14/2012
Event Time: 19:00 [CDT]
Last Update Date: 09/15/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(ii)(A) - DEGRADED CONDITION
Person (Organization):
MICHAEL KUNOWSKI (R3DO)

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

Event Text

DEGRADED CONDITION DUE TO INDICATIONS ON REACTOR VESSEL HEAD DURING DYE PENETRANT TEST

"On September 14, 2012, during the Byron Station Unit 1 refueling outage, it was determined that the results of planned Liquid Penetrant (PT) examinations performed on two previous overlay repairs of the reactor vessel head do not meet applicable acceptance criteria. Both penetrations require repairs prior to returning the vessel head to service. These indications are not in the reactor coolant pressure boundary; however they are very near the previously repaired J-groove weld. The examinations were being performed to meet the requirements of 10 CFR 50.55a(g)(6)(ii)(D) and ASME Code Case N-729-1, to ensure the structural integrity of the reactor vessel head pressure boundary. No ultrasonic indications have been identified at this time. Repairs are currently being planned, which will include buff of the rejectable area and retest, and will be completed prior to returning the vessel head to service. If retest of the rejectable areas is unacceptable, then additional repairs will be required prior to returning the vessel head to service.

"This condition is reportable pursuant to 10 CFR 50.72(b)(3)(ii)(A) since the as found indications did not meet applicable acceptance criteria referenced in ASME Code Case N-729-1 to remain in-service without repair. Any further examination failures and repairs will be updated under this ENS Notification.

"The NRC Resident Inspector has been notified."

The original indications that led to the two overlay repairs were discovered during ultrasonic testing and were reported to the NRC and assigned EN #46686.

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Power Reactor Event Number: 48312
Facility: FITZPATRICK
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-4
NRC Notified By: ROBERT BRUNS
HQ OPS Officer: DONG HWA PARK
Notification Date: 09/16/2012
Notification Time: 12:57 [ET]
Event Date: 09/16/2012
Event Time: 10:55 [EDT]
Last Update Date: 09/16/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(i) - PLANT S/D REQD BY TS
Person (Organization):
CHRISTOPHER NEWPORT (R1DO)

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

Event Text

TECHNICAL SPECIFICATION REQUIRED SHUTDOWN

"At 1055 EDT on September 16, 2012 with the James A. FitzPatrick Nuclear Power Plant (JAF) at 0% power while performing a planned reactor shutdown for a refueling outage, multiple control rods were conservatively declared inoperable due to the potential for control rod channel interference in the event of a seismic event. In response to [the] GE Hitachi Nuclear Energy (GEH) recommendations regarding the 10CFR Part 21 issue for control rod blade interference, JAF has implemented compensatory measures that require control rods with a Cell Friction Metric (CFM) greater than or equal to 100 be declared inoperable upon RPV pressure decreasing below 800 psig if a full stroke insertion test has not performed within the past 14 Effective Full Power Days (EFPD). During a planned shutdown, reactor pressure decreased below 800 psig before all control rods could be fully inserted using normal control rod insertion methods. With nine or more control rods inoperable in Mode 1 or 2, JAF Technical Specifications (LCO 3.1.3 Condition E) require the unit be placed in Mode 3 within 12 hours. This condition was entered at 1055 EDT and the unit was placed in Mode 3 at 1226 EDT. This event is reportable under 10CFR50.72(b)(2)(i), 'The initiation of any nuclear plant shutdown required by the plant's Technical Specifications.'

"The NRC Resident Inspector has been notified."

Page Last Reviewed/Updated Monday, September 17, 2012
Monday, September 17, 2012