United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for November 9, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
11/08/2012 - 11/09/2012

** EVENT NUMBERS **


48465 48469 48470 48472 48473 48474 48492 48493 48494 48495 48496

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Agreement State Event Number: 48465
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: SAINT JOSEPH HOSPITAL
Region: 4
City: EUREKA State: CA
County:
License #: 1703-12
Agreement: Y
Docket:
NRC Notified By: KENT PRENDERGAST
HQ OPS Officer: CHARLES TEAL
Notification Date: 10/31/2012
Notification Time: 18:50 [ET]
Event Date: 10/17/2012
Event Time: 15:37 [PDT]
Last Update Date: 10/31/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - POSSIBLE MEDICAL EVENT INVOLVING MISADMINISTRATION

"On 10/17/12, the licensee notified RHB (Radiation Health Branch) of an issue related to prostate brachytherapy and questioned if this falls into the category of Medical Event (ME). RHB is currently investigating this matter to evaluate if a ME had occurred.

"The RSO called RHB for guidance about three permanent prostate seed implants for which post-implant dosimetry showed less than ideal dose coverage of the gland. The RSO reiterated that none of these deviations were a surprise all were expected based on intra-operative experience. In one Iodine-125 case, poor coverage of the lateral base resulted from significant pubic arch interference. In the other two cases, both Palladium-103, poor coverage of the base occurred from vendor failure to disclose an additional unplanned spacer at the end of each seed strand.

"As stated, the D90 value (minimum dose to 90% of the CT-defined prostate one month following the implant) for the I-125 case was 77% and for the two Pd-103 cases was 68% and 53% of the dose prescribed as a minimum peripheral dose to the ultrasound-defined prostate +margin prior to the implant. The RSO requested RHB read this statement carefully, as it compares apples to oranges 'The RSO will make the case that the post-plan D90 is relevant as an assessment of plan and programmatic quality but is irrelevant for definition of a medical event'.

"The RSO indicated that the hospital's physicians do not prescribe by D90. What is prescribed is a minimum peripheral dose (MPD) to the ultrasound-defined prostate gland plus planning margin (PTV). A pre-plan is generated to deliver the intended MPD (145 Gy for I-125 monotherapy and 125 Gy for Pd-103 monotherapy) to the PTV. The resulting planned combination of radionuclide, source strength, and number of sources is what is approved, prescribed, ordered, and implanted.

"Very often, changes are made intra-operatively to account for implantation difficulties and clinical factors (deviation of urethra from predicted path, pubic arch interference, presence of more aggressive disease in a specific part of the gland, etc). In addition, extra seeds are ordered for each case, to be implanted at the discretion of the Authorized User (AU). Extra seeds may be implanted to boost areas of sparse coverage following implantation of planned seeds. Extra seeds may also be implanted to boost areas of known aggressive disease to a dose higher than the initial MPD. It is impossible to mentally arrive at a new dose that might correlate to a D90 on post-implant dosimetry under these conditions. The AU recognizes that this will result in an increase to the D90 on the post-plan but does not alter the dose on the written directive but only the number of sources (in part to of the written directive following implant but prior to release of the patient) to reflect the intra-operative changes. This is because the prescribed dose refers to a MPD for the pre-implant ultrasound prostate volume with margin (as our policy states). It was never meant to correlate with a D90 on a CT-defined prostate volume (which volume may be double the ultrasound-defined pre-implant volume) a month after the implant.

"As a result of the clinically discretional implantation of extra seeds, many of our D90 results in post-implant dosimetry actually exceed 100% of the prescribed dose. Several even exceed 120% of the 'prescribed' dose, and this is intentional. Nevertheless, the radionuclide, source strength, number of seeds, and duration of implant (permanent) indicated on part 2 of each written directive (the part completed following implantation but prior to release of the patient) correctly reflects what was done, as required by 10 CFR 35.41. The RSO called RHB about these three cases because the dose delivered to parts of these prostate glands was less than intended, an anticipated but initially unplanned result due to known but unplanned and uncontrollable outside factors.

"The Authorized Users for these cases are still reviewing the clinical data to determine what, if any, additional medical actions will be taken. Note that none of these cases meet the criteria for a medical event as recommended by the Nuclear Regulatory Commission's Advisory Committee on the Medical Use of Isotopes on October 18, 2011 (see attached). These criteria analyze the spatial distribution of seeds within octants of the gland as well as the overall D90 (threshold for which is lowered to 60% of prescription dose, and only in conjunction with failure of the spatial analysis). In each of these cases (and in contrast to what happened in the VA cases), very few seeds (only a few percent) were implanted outside the planning margin of the prostate CTV. Even by the older document the state reference, the May 18, 2011 Prostate Permanent Implant Brachytherapy and Associated Medical Event Questions and Answers from Clarification of Current Guidance for Prostate Permanent Implant Brachytherapy, the hospital assert (as in Case 2) that ' in accordance with NRC regulations, a ME has not occurred, since the delivered activity is equal to the prescribed activity for the treatment site (as defined by the AU). Even though the D90 values differ by more than 20 percent; the AU does not use D90 to prescribe dose, and is therefore, not required to use D90 to perform the regulatory evaluation of the prescribed dose'."

CA 5010 Number: 101712

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Agreement State Event Number: 48469
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ATLANTA HEART ASSOCIATES, P.C.
Region: 1
City: ATLANTA State: GA
County:
License #: GA 1271-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 14:56 [ET]
Event Date: 08/03/2009
Event Time: [EDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LATE REPORTING FOR DIAGNOSTIC MISADMINISTRATION

The following information was provided by the State of Georgia via email:

"Licensee contacted the Department [Georgia Radioactive Materials Program] via telephone on 8/12/09 reporting that a patient who underwent a nuclear cardiology treadmill stress test on 8/3/09 resulted in an embryo/fetus exposure greater than 500 mRem. The Department received a report from the licensee on 8/14/12 describing that prior to treatment the patient declared to the licensee that she was not pregnant and the licensee followed in house protocols in which all female patients under the age of 55 are asked if they are currently pregnant or breastfeeding. In the event that a patient is unsure the licensee postpones testing until a negative pregnancy test can be obtained. The patient later informed the licensee of her pregnancy on 8/10/09. Isotopes and activity administered to the patient were as follows: Tc-99m 28.2 mCi & Tl-201 3.62 mCi with a Total Activity of 31.82 mCi. RSO for the licensee & consulting medical physicists conducted a dose determination and the conclusion was that the embryo/fetus did receive an effective dose equivalent in excess of 500 mRem. The results were forwarded to the patient's OBGYN."

This was a diagnostic misadministration that did not involve contamination.

Report: GA-2009-12i

NMED# 090811

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Agreement State Event Number: 48470
Rep Org: GEORGIA RADIOACTIVE MATERIAL PGM
Licensee: ATLANTA HEART ASSOCIATES, P.C.
Region: 1
City: ATLANTA State: GA
County:
License #: GA 1271-1
Agreement: Y
Docket:
NRC Notified By: TRAVIS CARTOSKI
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 14:56 [ET]
Event Date: 08/17/2009
Event Time: [EDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JAMES NOGGLE (R1DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - LATE REPORTING FOR DIAGNOSTIC MISADMINISTRATION

The following information was provided by the State of Georgia via email:

"Licensee informed the Department [Georgia Radioactive Materials Program] via written correspondence dated 8/28/09 that a patient who underwent a nuclear cardiology treadmill stress test on 8/17/09 resulted in an embryo/fetus exposure greater than 500 mRem. Prior to treatment the patient declared to the licensee that she was not pregnant and the licensee followed in house protocols in which all female patients under the age of 55 are asked if they are currently pregnant or breastfeeding. In the event that a patient is unsure the licensee postpones testing until a negative pregnancy test can be obtained. The patient later informed the licensee of her pregnancy on 8/27/09. Isotopes and activity administered to the patient were as follows: Tc-99m 26.9 mCi & Tl-201 5.38 mCi with a Total Activity of 32.28 mCi. RSO for the licensee & consulting medical physicists conducted a dose determination and the conclusion was that the embryo/fetus did receive an effective dose equivalent in excess of 500 mRem. The results were forwarded to the patient's OBGYN."

This was a diagnostic misadministration that did not involve contamination.

Report: GA-2009-18i

NMED# 090812

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Agreement State Event Number: 48472
Rep Org: COLORADO DEPT OF HEALTH
Licensee: TOWN OF LYONS
Region: 4
City: LYONS State: CO
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 16:55 [ET]
Event Date: 10/22/2012
Event Time: [MDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - DAMAGED TRITIUM EXIT SIGN

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

"The Colorado Department of Public Health and Environment received notification on 10-23-12 from Town of Lyons, Town Hall, 432 Fifth Avenue, Lyons, CO 80540, that a tritium exit sign was found on the floor when an employee entered the building on 10-22-2012. This exit sign was installed on 10-19-12. It is presumed the installation was incorrectly completed causing the sign to fall. An employee who entered the building picked the sign up and reported the damaged sign to the Public Works Director who contacted the Radioactive Materials Unit on 10-23-12 at 1330 PDT to report the damaged exit sign. The tube containing the Tritium is reported as damaged.

"The sign was reported installed on 10-19-12. The sign fell from the ceiling during the weekend, and was found on Monday, 10-22-12 just inside the front entrance to the building. The licensee was provided documentation regarding how to package and ship the sign back to the manufacturer. The documentation emailed to him included the NRC NUREG -1556, Vol. 16 Appendix L.

"Maker of the sign is Best Lighting Products. The model number is SLXTU1RB10 and serial number is 232970. The date it was reported shipped to the licensee was 12/28/10.

"The activity of H-3 is 7.03 Curies."

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Agreement State Event Number: 48473
Rep Org: COLORADO DEPT OF HEALTH
Licensee: WESTIN HOTEL -WESTMINSTER
Region: 4
City: WESTMINSTER State: CO
County:
License #: GENERAL
Agreement: Y
Docket:
NRC Notified By: LINDA BARTISH
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 16:55 [ET]
Event Date: 10/02/2012
Event Time: [MDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)
ILTAB (EMAI)

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

Event Text

AGREEMENT STATE REPORT - LOST TRITIUM EXIT SIGN

The following information was provided by the State of Colorado via email:

"The Colorado Department of Public Health and Environment received notification on 10-2-12 from Westin Hotel - Westminster, 10600 Westminster Blvd., Westminster, CO 80030. Phillip McDonald, Engineering Manager, reported a contractor removed and disposed of one exit sign during a remodel project when a new front entrance was completed, (no date given on project).

"Maker of Sign: Isolite
Model Number: SLX60
Serial Number: 12-02897
Activity (Curies of H-3): 6.2 Curies
Date Manufacture Shipped: 1/31/2012
Date of Loss: No Date Reported for project.
Location of Sign When Lost: Front entrance

"Other Details: Per the letter submitted by Phillip McDonald, he states 'I do remember this device being installed, but I was unaware it had radioactive material inside or the responsibility of tracking this device. Our restaurant was remodeled this year and the contractor removed the device and disposed of it'."

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

This source is not amongst those sources or devices identified by the IAEA Code of Conduct for the Safety & Security of Radioactive Sources to be of concern from a radiological standpoint. Therefore is it being categorized as a less than Category 3 source

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Agreement State Event Number: 48474
Rep Org: TEXAS DEPARTMENT OF HEALTH
Licensee: PARADIGM CONSULTANTS INC
Region: 4
City: HOUSTON State: TX
County:
License #: 04875
Agreement: Y
Docket:
NRC Notified By: KAREN BLANCHARD
HQ OPS Officer: JOHN KNOKE
Notification Date: 11/01/2012
Notification Time: 17:46 [ET]
Event Date: 11/01/2012
Event Time: [CDT]
Last Update Date: 11/01/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RICK DEESE (R4DO)
FSME EVENT RESOURCE (EMAI)

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

Event Text

AGREEMENT STATE REPORT - DAMAGED MOISTURE/DENSITY GAUGE

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

"On November 1, 2012, the licensee notified the Agency that one of its Campbell-Pacific Model MC-3 moisture/density gauges had been run over by a pickup truck at a temporary work site in Houston, Texas. The gauge contained one 10 millicurie cesium-137 source and one 50 millicurie americium-241/beryllium source. The sources were in the safe position when it was run over. The source rod was broken off at the top of the housing. The gauge was taken to a gauge service company where it was checked. There was no leakage of radiation. A determination will be made by the licensee as to whether they will have the gauge repaired or replaced. There was no exposure to any individual as a result of this incident.

"Gauge Information:
Mfg: Campbell-Pacific
Model: MC-3
SN: M38118595

"Source Information:
cesium-137 -- 10 millicuries -- SN: C8595
americium-241/beryllium -- 50 millicuries -- A8595"

Texas Incident Number: I-9005

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Part 21 Event Number: 48492
Rep Org: FISHER CONTROLS INTERNATIONAL, LLC
Licensee: FISHER CONTROLS INTERNATIONAL, LLC
Region: 3
City: MARSHALLTOWN State: IA
County:
License #:
Agreement: Y
Docket:
NRC Notified By: CHAD ENGLE
HQ OPS Officer: VINCE KLCO
Notification Date: 11/08/2012
Notification Time: 10:11 [ET]
Event Date: 11/07/2012
Event Time: [CST]
Last Update Date: 11/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
GLENN DENTEL (R1DO)
MARVIN SYKES (R2DO)
CHRISTINE LIPA (R3DO)
THOMAS FARNHOLTZ (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 REPORT- COMMERCIAL GRADE DEDICATION NOT PROPERLY APPLIED TO BUTTERFLY VALVES

The following information was received by facsimile:

"While reviewing an order for a Type 9200 Butterfly Valve, it was discovered that some parts [shipped from Marshalltown, Iowa from 2009-present] had not been identified for Commercial Grade Dedication, These parts were considered Essential-to-Function and were needed for the valve assembly to perform its safety-related function(s).

"[The vendor] then extended its review to all safety-related orders going back to 2009. This review confirmed that the failure to dedicate was not confined to Type 9200 butterfly valves. The beginning of 2009 was selected because [an audit follow-up was] performed in January, 2009. A key point of emphasis during the audit was commercial grade dedication, with a recommended outcome being the addition of guidance on commercial grade dedication with all new quotations. Therefore, the 2009 audit brought clarity and consistency in approach, that was not always applied correctly between January, 2009 thru October, 2012.

"It is [vendor's] opinion that while the affected equipment identified as safety-related was not properly dedicated, the failure to dedicate does not appear to pose an inherent safety risk based on currently available Information. The reason being that much of the equipment affected by [the vendor's] error were items such as mounting kits, wherein [the vendor] failed to dedicate the hardware used to mount the instrument (i.e., the bracket and screws), but did properly dedicate the instrument. Additionally, in forming this opinion, [the vendor] has taken into account that there are no known field issues with the affected equipment and all such possibly non-dedicated equipment passed the required standard testing."

U.S. nuclear plants affected include the following:

D.C. Cook; Millstone; Surry; McGuire; San Onofre; Indian Point; Palisades; Clinton; Peach Bottom; Beaver Valley; Cooper; Palo Verde; Brunswick; Hope Creek/Salem and Watts Bar. It is noted that numerous foreign facilities are also affected.

If there are any technical question, contact the Fisher Quality Manager (George Baitinger) : Fax: (641) 754-2854 or Phone: (641) 754-2026.

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Part 21 Event Number: 48493
Rep Org: ABB INC. (MEDIUM VOLTAGE SERVICE)
Licensee: ACCUTREX PRODUCTS, INC.
Region: 1
City: FLORENCE State: SC
County:
License #:
Agreement: Y
Docket:
NRC Notified By: DAVID BROWN
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/08/2012
Notification Time: 14:55 [ET]
Event Date: 09/14/2012
Event Time: [EST]
Last Update Date: 11/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
GLENN DENTEL (R1DO)
MARVIN SYKES (R2DO)
CHRISTINE LIPA (R3DO)
THOMAS FARNHOLTZ (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - AN OPERATING MECHANISM FRONT COVER FAILED DURING LICENSEE RECEIPT INSPECTION

The following information was received by facsimile:

"[ABB, Inc. provided] notification of a failure to comply with specifications associated with an operating mechanism front cover P/N 707939A00 used in low voltage electrically operated K-Line circuit breakers. A single occurrence of a newly manufactured circuit breaker failure to close was noted during Next Era Energy Seabrook Station receiving inspection supported by an ABB Medium Voltage Service Field Service Engineer. This circuit breaker was set up and tested satisfactorily during ABB cycle testing, inspection and commercial grade dedication prior to shipping. It was noted during the Seabrook receiving inspection that the control device plunger and secondary close latch were misaligned. Replacement of the operating mechanism front cover improved this alignment and the circuit breaker receipt inspection was completed satisfactorily. Inspection of the subject operating mechanism front cover indicates cause of the misalignment is due to incorrect hole locations for mounting the control device. This operating mechanism front cover was manufactured by Accutrex Products, Inc., an ABB approved vendor.

"Identification of the Subject component: ABB part numbers 707939A00 and 707939B00 operating mechanism covers. These covers are used in operating mechanisms for the K-Line electrically operated circuit breakers rated 2000 amps and below.

"Because of the large potential variety of usages of the affected circuit breakers, ABB (Medium Voltage Service) cannot determine if the potential for a substantial safety hazard exists at any licensee's facility if control device plunger and secondary close latch are misaligned. It is recommended the Licensees determine if the circuit breaker control device plunger and secondary close latch are misaligned at the next convenient maintenance opportunity defined in the ABB K-Line circuit breaker Information Bulletin."

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Part 21 Event Number: 48494
Rep Org: SCIENTECH
Licensee: SCIENTECH
Region: 4
City: IDAHO FALLS State: ID
County:
License #:
Agreement: N
Docket:
NRC Notified By: VINCE CHERMAK
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/08/2012
Notification Time: 16:28 [ET]
Event Date: 10/11/2012
Event Time: [MST]
Last Update Date: 11/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
21.21(d)(3)(i) - DEFECTS AND NONCOMPLIANCE
Person (Organization):
MARVIN SYKES (R2DO)
THOMAS FARNHOLTZ (R4DO)
PART 21 GROUP (EMAI)

Event Text

PART 21 - POTENTIAL GROUNDING PATHWAY BETWEEN HEAT SINK AND CHASSIS OF CONTROL MODULES

The following information was obtained from the vendor via facsimile:

"This report notifies the Nuclear Regulatory Commission of a defect in CMM830 and TMD830 [modules] that could result in an unintended ground loop that could lead to a low impedance connection between the module output circuitry and chassis.

"There is a mechanical interference between the sheet metal housing and the heat sink for transistor Q1 on the master board assembly. The heat sink of transistor Q1 is connected to the drain of Q1, which is the output of the current loop circuit. Should the heat sink of transistor Q1 short to chassis because of the interference, then an unintended ground loop could lead to a low impedance connection between the module output circuitry and chassis. The effect of grounding Q1 to chassis will vary with the application.

"If Q1 is grounded to the chassis, but no ground connection exists in the output loop, the incidental ground may produce no observable effect on the performance of the module. In that case, any subsequent independent event which introduces a ground in the output loop will cause a loop fault, potentially affecting the module output current.

"Alternatively, if Q1 and chassis are initially isolated, the defect may not manifest unless vibration causes mechanical wearing of the oxide coating of the heat sink. It is possible that a seismic event could cause sufficient wearing to initiate a loop fault, again potentially affecting the module output current."

The affected facilities are HB Robinson and Turkey Point.

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Power Reactor Event Number: 48495
Facility: OYSTER CREEK
Region: 1 State: NJ
Unit: [1] [ ] [ ]
RX Type: [1] GE-2
NRC Notified By: BRYAN EAGAN
HQ OPS Officer: DONG HWA PARK
Notification Date: 11/08/2012
Notification Time: 16:55 [ET]
Event Date: 11/08/2012
Event Time: 10:20 [EST]
Last Update Date: 11/08/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
Person (Organization):
GLENN DENTEL (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

LOSS OF EMERGENCY PLANNING ZONE SIRENS

"Prior to 1020 EST on November 8, 2012, 4 out of 42 Emergency Planning Zone (EPZ) Sirens remained inoperable, due to issues caused by Hurricane Sandy. At 1020 on November 8, 2012, Oyster Creek was notified by ANS, the provider of Exelon siren maintenance, that due to the recent snow storm, 11 out of 42 sirens in the Oyster Creek Emergency Planning Zone were inoperable. 11 out of 42 sirens exceeds Exelon's reporting threshold of 25 percent or more sirens out of service. Therefore, an 8-hour report is required under 10 CFR 50.72(b)(3)(xiii) due to a 'Loss of Emergency Preparedness Capabilities.'

"Prior to the submission of this report, Oyster Creek was notified by ANS that 4 of the 11 inoperable sirens were returned to service.

The licensee will notify the NRC Resident Inspector.

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Power Reactor Event Number: 48496
Facility: SUSQUEHANNA
Region: 1 State: PA
Unit: [ ] [2] [ ]
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: DAVE WALSH
HQ OPS Officer: VINCE KLCO
Notification Date: 11/09/2012
Notification Time: 03:03 [ET]
Event Date: 11/09/2012
Event Time: 01:18 [EST]
Last Update Date: 11/09/2012
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
50.72(b)(2)(iv)(A) - ECCS INJECTION
Person (Organization):
GLENN DENTEL (R1DO)

Unit SCRAM Code RX CRIT Initial PWR Initial RX Mode Current PWR Current RX Mode
2 M/R Y 90 Power Operation 0 Hot Shutdown

Event Text

UNIT 2 MANUAL SCRAM DUE TO LOSS OF THE INTEGRATED CONTROL SYSTEM

"At approximately 0118 hours [EST] on November 9, 2012, Susquehanna Steam Electric Station Unit Two reactor was scrammed by plant operators due to a loss of ICS (Integrated Control System; which controls the reactor feed and reactor recirculation systems). The reactor operator placed the mode switch in shutdown when reactor water level reached +25 inches and lowering. All control rods inserted and both reactor recirculation pumps tripped at -38 inches. Reactor water level lowered to -52 inches causing Level 3 (+13 inches) and level 2 (-38 inches) isolations. HPCI and RCIC both automatically initiated. HPCI was overridden prior to injection and RCIC was utilized to restore reactor water level to the normal band. All isolations and initiations at this level occurred as expected. No steam relief valves opened. Pressure was controlled via turbine bypass valve operation. All safety systems operated as expected.

"The [Unit 2] reactor is currently stable in Mode 3. An investigation into the cause of the loss of ICS is underway.

"Unit One continued power operation [at 78% power].

"The NRC Resident Inspectors were notified. A press release will occur."

The licensee will inform the State of Pennsylvania.

Decay heat removal is being maintained through the main condenser. On-site electrical power is in the normal configuration.

Page Last Reviewed/Updated Friday, November 09, 2012
Friday, November 09, 2012